title: Management of the difficult airway. A case of failed fiberoptic intubation.
abstract: BACKGROUND
  Fiberoptic intubation is the current gold standard for the management of difficult intubation. Nevertheless, in rare circumstances even fiberoptic intubation fails.
  
  
  METHODS
  We describe the case of a female patient suffering from neurofibromatosis Recklinghausen and a giant malignant schwannoma on the neck obstructing the pharynx and compromising respiration. Based on the clinical presentation and the MRI findings, difficulties in airway management were anticipated and fiberoptic intubation of the awake patient was planned.
  
  
  RESULTS
  After localizing the vocal cords it was not possible to advance the tube into the trachea due to the severe deviation of the glottis. A decision was made to cancel any further fiberoptic intubation attempts and a conventional tracheotomy was performed under local anaesthesia without problems.
  
  
  CONCLUSIONS
  This case illustrates that even awake fiberoptic intubation has its failure rate, due to inability to visualize the larynx, inability to advance the tube over the fiberscope (as in the present case), or inability to direct the tube towards the larynx. Due to the extreme deviation of the larynx other established techniques for difficult intubation were not deemed appropriate in this case. Therefore, weighing the risks and benefits, a decision was made to perform a tracheotomy under local anaesthesia.
authors.affiliation: Department of Anaesthesiology, Hospital of the Christian-Albrecht-University, Kiel, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Wulf
authors.forename: G
authors.initials: G
authors.lastname: Brinkmann
authors.forename: M
authors.initials: M
authors.lastname: Rautenberg
mesh_terms: D000402:Airway Obstruction / Q000209:etiology*; D005260:Female; D005336:Fiber Optic Technology; D006258:Head and Neck Neoplasms / Q000150:complications / Q000601:surgery; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D008875:Middle Aged; D009456:Neurofibromatosis 1 / Q000150:complications / Q000601:surgery; D014140:Tracheotomy