Airway Management challenges due to and limited mouth opening and previous cheek flap reconstruction: A case report

Airway Management challenges due to and limited mouth opening and previous cheek flap reconstruction: A case report | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 23 October 2025 V1 Latest version Share on Airway Management challenges due to and limited mouth opening and previous cheek flap reconstruction: A case report Authors : Reza Tahmasebi , Pegah Arman 0000-0001-8668-4551 [email protected] , Alireza Babajani , Ali Khalafi , Zahra Emadi Zemam , and Yasin Goodarzi Authors Info & Affiliations https://doi.org/10.22541/au.176122282.21571141/v1 224 views 143 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract The patient is a 64-year-old woman who was admitted to the hospital as an emergency with a complaint of epistaxis. The patient had also been admitted to the hospital 13 days ago due to epistaxis and was a candidate for endoscopic nasal surgery due to the frequent recurrence of this bleeding. Title Page Airway Management challenges due to and limited mouth opening and previous cheek flap reconstruction: A case report Reza Tahmasebi 1 , Pegah Arman 2* , Alireza Babajani 3 , Ali Khalafi 4 , Zahra Emadi Zemam 5 , Yasin Goodarzi 6 1 Department of Anesthesia, Hamadan University of Medical Sciences, Hamedan, Iran. https://orcid.org/0000-0003-3662-2912. 2 Department of Anesthesiology, School of Paramedicine, Hamadan University of Medical Sciences, Hamadan, Iran. https://orcid.org/0000-0001-8668-4551. [email protected] 3 Faculty Member, department of Anesthesiology, School of Allied Medical Sciences, Alborz University of Medical Sciences, Karaj, iran. https://orcid.org/0000-0002-4865-1051. [email protected] 4 Associate professor, Department of Anesthesiology, School of Allied Medical Scinces, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. https://orcid.org/0000-0002-9534-162X. [email protected] 5 Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran. [email protected] 6 Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran. https://orcid.org/0009-0002-0981-4433. [email protected] Informed consent All stages of the publication of the article were explained to the patient and informed consent was obtained, all patient identification information has been removed to ensure confidentiality. Published images are anonymous and non-identifiable. ABSTRACT The patient is a 64-year-old woman who was admitted to the hospital as an emergency with a complaint of epistaxis. The patient had also been admitted to the hospital 13 days ago due to epistaxis and was a candidate for endoscopic nasal surgery due to the frequent recurrence of this bleeding. Considering that the patient had undergone cheek flap surgery two years ago due to SCC in the jaw and cheek area and as a result of previous surgeries, the patient faced some limitations in opening the mouth. The limitation in opening the mouth and the presence of a plate fixator in the oral space made it difficult to control the patient’s airway. After consultation with the anesthesia team, the patient’s tracheal intubation was performed without complications. The surgery lasted 1 hour and the patient was extubated without any complications. Keywords: Airway Management, Mouth Diseases, facial neoplasms, case report. Key Clinical Message Airway management in patients with a history of head and neck surgery and limited mouth opening poses a critical challenge. Meticulous preoperative planning by the anesthesia team, including specialized consultation and tailored techniques, is essential to ensure safe and uncomplicated outcomes in such complex cases\RL. Introduction Although induction of anesthesia is a safe procedure, difficult airway control can pose many risks to patients. One of the most important ways to reduce the risks of airway control in patients is to carefully assess the airway before induction of anesthesia. During airway assessment, examination of the oral cavity and the degree of mouth opening can be important factors in identifying the degree of difficulty in controlling the patient’s airway [1,2]. Case examination A 64-year-old female patient presented with complaints of epistaxis. The patient’s blood pressure at the time of presentation was 110/90, and therefore the diagnosis of epistaxis with hypertension was rejected. The patient did not report a history of trauma to the facial area. Given that her bleeding could not be controlled and she had been hospitalized for epistaxis 13 days earlier, she was a candidate for endoscopic nasal surgery. The patient has a history of hypertension and diabetes. Due to underlying diseases, internal medicine and cardiology consultations were performed on the patient, and the cardiology consultation recommended that the patient’s heart rate and blood pressure not increase during anesthesia. The patient had a history of squamous cell carcinoma (SCC) and had undergone surgery on the right maxilla and buccal for treatment. During the treatment of SCC, the patient underwent a flap in the maxilla and buccal area that limited her mouth opening. On the other hand, the patient’s personalized prosthesis was protruding due to tissue resorption in the patient’s oral and facial space. During the anesthesia consultation, the anesthesiologist noted that the patient’s mouth could only be opened 2 cm and that the pharyngeal view was reduced due to the protrusion of the flap prosthesis into the patient’s oral cavity, so the anesthesiologist realized that there was a problem with intubation. During clinical examination, the patient was diagnosed with a class 4 malampatosis and the sterno-sternal distance was 13 cm. Differential diagnosis The limitation in the patient’s mouth opening and the presence of the prosthesis base in the oral space raise the question of what is the best method for intubation (Figure 1)? Given the results of the patient’s cardiac consultation, which recommended not to increase the patient’s heart rate and blood pressure, and the difficulty in controlling the patient’s airway, the anesthesia team concluded during the consultation that the patient should be intubated using a glidescope. The patient’s baseline tests were as follows: Hb = 10, FBS = 105, HR = 76, BP = 118/87, SPO2 = 98%, Plat = 174000, Hct = 31.7, WBC = 7800. The patient’s weight was 58 kg. Anaesthetic induction was performed with etomidate (110 mg) and 2% lidocaine (30 mg). The patient was then intubated using a glidescope (blade Size 3) and a size 7 endotracheal tube. The patient’s intubation was performed without risk\RL)Figure2). To maintain anesthesia, isoflurane with an alveolar concentration of 1.2 and N2O gas at a rate of 3 liters per minute in an O2 gas mixture at a rate of 3 liters per minute were used. Cardiac and respiratory monitoring was . Discussion The aim of this article is to review airway management strategies in patients with severe limitation of mouth opening. Anatomical abnormalities in different patients, due to underlying diseases and previous surgeries, can lead to limitation of mouth opening, which is a major challenge in patient airway management and intubation [3]. Our goal in presenting this article was to share our experience in airway control in a patient with a history of maxillofacial surgery who had limited mouth opening. Preoperative consideration Performing a complete clinical examination before surgery to detect difficulty in establishing the patient’s airway is one of the most important points of pre-anesthesia consultation, which can be effective in identifying risk factors and increasing the anesthesia team’s readiness for crisis management. A complete examination of the patient’s airway can include important tests such as the Mallampati test, SARI Protocol,evaluation of the thyromentum distance, restriction of neck movements, etc [1]. and given that diabetics are prone to joint dislocation and their skeleton is vulnerable, one of the most important points in the pre-operative evaluation of these patients is the evaluation of the range of motion of the neck joint. Unfortunately, in the case under study, this test was not performed before surgery. Intraoperative consideration Intraoperative considerations for these patients can be challenging, and the most important step in patients with a difficult airway is to establish a secure airway to reduce the risk of non-ventilation [6]. Choosing an appropriate airway management method for patients can be life-saving [7]. During intubation, one of the problems that can arise from the patient’s limited mouth opening is the limited visibility of the pharyngeal space, and to reduce this risk, the anesthesia team decided to use a gliding scope, which can provide a good view of the glottis. Given the pin base in the patient’s oral space, which could have caused a tear in the endotracheal tube cuff and limited the oral space itself, the use of a gliding scope seemed a logical approach. It should be noted that the use of long-acting muscle relaxants can increase the risk of hypoxia by stopping the patient’s spontaneous breathing when airway management is impossible [8]. Accordingly, the anesthesia team decided not to inject muscle relaxants until a safe airway was established. It should be noted that not injecting muscle relaxants can increase sympathetic stimulation during intubation and pose cardiovascular risks to patients. [9] Therefore, the anesthesia team decided to use etomidate, which is a safe drug given the patient’s cardiovascular problems [10]. On the other hand, using a glidescope instead of a laryngoscope could have reduced airway irritation by reducing the risk of intubation failure. Postoperative consideration Postoperative considerations in these patients depend on the quality of the patient’s spontaneous breathing. However, given the risk of airway obstruction after general anesthesia, it is recommended that the patient be extubated awake to reduce the risks [11]. It is also necessary to establish complete respiratory monitoring for the patient during the patient’s stay in recovery. Conclusion Limited mouth opening is a risk factor for airway control that can make intubation difficult. When patients with limited mouth opening require general anesthesia, careful airway assessment before anesthesia can help identify risks and help determine the best airway management method. Awake extubation can also reduce the risk of postoperative reintubation in these patients. Ethical Considerations All stages of the research were conducted under the supervision of the Ethics Committee of Hamadan University of Medical Sciences. Informed consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. All patient identifiers have been removed to ensure confidentiality. Conflicts of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article\RL. Funding statement The authors received no financial support for the research, authorship, and/or publication of this article. Acknowledgements The authors thank the patient and her family for permission to publish the information in this article. Author(s) Contribution P.A. and R.T. provided clinical anesthesia care, including airway management and intraoperative anesthesia. Z.E. and Y.G. were responsible for data curation and documentation of the anesthesia process. P.A. and A.B. wrote the original draft of the manuscript. A.K.H. critically reviewed and edited the manuscript. All authors read and approved the final version. References [1] Muhammad IK, Arman P, Zamani M, Manoucherian N. Investigating the Airway Assessment of COPD Patients Based on the SARI Protocol: A Descriptive Cross-Sectional Study. Archives of Anesthesiology and Critical Care. 2025. [2] Schnittker R, Marshall S, Berecki‐Gisolf J. Patient and surgery factors associated with the incidence of failed and difficult intubation. Anaesthesia. 2020;75(6):756-66. [3] Galway U, Wang M, Deeby M, Zura A, Riter Q, Abdelmalak B. Recognition and management of the difficult airway—a narrative review and update on the latest guidelines. Journal of Oral and Maxillofacial Anesthesia. 2023;2. [4] Thiele EL, Nemergut EC. Miller’s anesthesia. Anesthesia & Analgesia. 2020 Jun 1;130(6):e175-6. [5] Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM. Evaluation and management of the physiologically difficult airway: consensus recommendations from Society for Airway Management. Anesthesia & Analgesia. 2021 [6] Jung H. A comprehensive review of difficult airway management strategies for patient safety. Anesthesia and Pain Medicine. 2023 Oct 31;18(4):331-9. [7] Miller KA, Goldman MP, Nagler J. Management of the difficult airway. Pediatric Emergency Care. 2023 Mar 1;39(3):192-200. [8] Altaweel H, Kabbani MS. Access and Expert Management of the Airway. InManual of Pediatric Cardiac Care: Volume II 2024 Jul 30 (pp. 67-70). Singapore: Springer Nature Singapore. [9] Pardo M, editor. Miller. Anestesia básica. Elsevier Health Sciences; 2024 Sep 13. [10] Hu B, Zhang M, Wu Z, Zhang X, Zou X, Tan L, Song T, Li X. Comparison of remimazolam tosilate and etomidate on hemodynamics in cardiac surgery: a randomised controlled trial. Drug Design, Development and Therapy. 2023 Dec 31:381-8. [11] Aljonaieh K. Awake tracheal extubation, can be anticipated? case reports. Saudi Journal of Anaesthesia. 2024 Jan 1;18(1):117-9. Supplementary Material File (figures.docx) Download 902.34 KB Information & Authors Information Version history V1 Version 1 23 October 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords anesthesia emergency medicine ethics nursing Authors Affiliations Reza Tahmasebi Hamedan University of Medical Sciences View all articles by this author Pegah Arman 0000-0001-8668-4551 [email protected] Hamadan University of Medical Sciences School of Paramedicine View all articles by this author Alireza Babajani Alborz University of Medical Sciences View all articles by this author Ali Khalafi Ahvaz Jondishapour University of Medical Sciences View all articles by this author Zahra Emadi Zemam Hamadan University of Medical Sciences Medical School View all articles by this author Yasin Goodarzi Hamedan University of Medical Sciences View all articles by this author Metrics & Citations Metrics Article Usage 224 views 143 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Reza Tahmasebi, Pegah Arman, Alireza Babajani, et al. Airway Management challenges due to and limited mouth opening and previous cheek flap reconstruction: A case report. 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