6  Surgical Management of the

Difficult Adult Airway

Nasir Islam Bhatti

Key Points
■ The difficult airway must be considered to involve at least one of the following: difficult
laryngoscopy and difficult mask ventilation and/or difficult tracheal intubation.
■ It is important to realize that identification of the difficult airway before manipulation is the first
step in preparing for optimal patient care and a safe outcome.
■ The otolaryngologist with training and expertise in endoscopic techniques—such as rigid and

flexible laryngoscopy, bronchoscopy, and the ability to provide open surgical access to the airway—
is an essential member of the difficult-airway response team.
■ Techniques commonly used in management of the difficult airway include awake fiberoptic

laryngoscopy, intubation through a laryngeal mask airway with or without fiberoptic laryngoscopy,
intubation by direct laryngoscopy with an anterior commissure laryngoscope, and the surgical airway.
■ Awake fiberoptic intubation should be considered in the obese patient with obstructive sleep

apnea, in conditions that result in supraglottic obstruction (e.g., edema, supraglottic tumor), and in
patients with a history of difficult intubation by other techniques.
■ Lack of training and experience in fiberoptic bronchoscopy is a common cause of failure in awake

fiberoptic intubation.
■ Once the “cannot intubate/cannot ventilate” situation has been identified, immediate consideration
should be given to surgical airway access.

F ailure to maintain a patent airway can result in catastrophic
events for the patient, including brain damage or death. In
1990, more than 85% of all respiratory event–related closed
malpractice claims involved an anoxic brain injury or death.1
Difficulties with intubation and emergent airway issues remain
the leading causes of serious intraoperative complications.2 As
many as 30% of deaths attributable to anesthesia involve failure
to manage the difficult airway.3 In any given patient, the risk of
anoxic injury or death increases in direct proportion to the
degree of difficulty in maintaining a patent airway.4 Any scien-
tific or clinical description of the difficult airway must include
clearly defined terminology.
This chapter considers the difficult airway as involving three
distinct but often clinically related scenarios. The first of these
is difficult tracheal intubation, which exists when multiple attempts
are needed in the presence or absence of tracheal disease. An
infinitely difficult intubation means the trachea cannot be intu-
bated under direct vision, despite full paralysis, optimal head
and neck positioning, cricoid pressure, forceful anterior eleva-
tion of the laryngoscope blade, and attempts by multiple opera-
tors with a variety of laryngoscope blades.4 The incidence of
failed endotracheal intubation ranges from 5 to 35 per 10,000
patients.5,6
The second difficult airway scenario is the difficult laryngos-
copy, described as inability to visualize any portion of the larynx,
vocal folds, or glottic aperture after multiple attempts at con-
ventional laryngoscopy. Many investigators include grades III
and IV or grade IV alone, according to the Cormack-Lehane7
original grading of the rigid laryngoscopic view. For studies of
difficult laryngoscopy to be reliable, and for the preceding
laryngoscopic grading system to be helpful, the reported grades
must describe the best view that was obtained, which in turn
depends on the best performance of laryngoscopy.4 The techni-
cal components that optimize laryngoscopy include optimal
position, complete muscle relaxation, firm forward and upward
traction on the laryngoscope, and, if necessary, firm external
laryngeal manipulation with cricoid pressure. External laryn-
geal pressure, for example, may reduce the incidence of a
grade III view from 9% to 1.3%.8 Theoretically, if the preceding
technical components of laryngoscopy are used, and the pitfalls
are avoided, all laryngoscopists, both novice and expert, should
have close to the same laryngoscopic view. Difficult laryngos-
copy is synonymous with difficult intubation in most patients.
A grade II or III laryngoscopic view that requires multiple
attempts with different blades is relatively common and occurs
in 100 to 1800 of 10,000 patients.9 The incidence of a higher
grade III laryngoscopic view ranges from 100 to 400 per 10,000
patients.10,11
The third difficult airway scenario is difficult mask ventilation
(DMV), a condition in which it is not possible to provide ade-
quate facemask ventilation as a result of inadequate mask seal
or excessive resistance because of inadequate patency of the
airway.4 Langeron and colleagues12 compiled a list of predictors
of DMV based on a survey of anesthesiologists, asking them to
rate the difficulty of facemask ventilation; this difficulty rating
was based on whether it was clinically relevant and could have
led to potential problems if mask ventilation had to be main-
tained for a longer time. Six reasons for DMV were identified:

86
 6  |  SURGICAL MANAGEMENT OF THE DIFFICULT ADULT AIRWAY 87
1) inability of the unassisted anesthesiologist to maintain oxygen
saturation to greater than 92% using 100% oxygen and positive-
pressure mask ventilation, 2) significant gas flow leak by the
facemask, 3) the necessity to increase the gas flow to greater
than 15 L/min and to use the oxygen flush valve more than
twice, 4) no perceptible gas movement, 5) the necessity 
to perform a two-handed mask-ventilation technique, and 
6) change of operator required.
The incidence of DMV is difficult to estimate in that no
standard definition has been used universally by researchers,
so each study needs to be carefully read to determine the defini-
tion used. Langeron and colleagues12 reported a 5% incidence
of DMV with 1 in 1502 patients being impossible to ventilate
with a facemask. A very significant finding from this study is
that DMV conferred a fourfold increased risk for difficult intu-
bation and a twelvefold increase in the risk for an impossible
intubation.
The incidence of the ultimately critical failed airway, the
cannot intubate/cannot ventilate situation, can be estimated;
this is because it frequently results in anoxic brain injury or
death, the incidence of which ranges from 0.01 to 2 per 10,000
patients.13,14 Although the cause of this dire apneic or obstruc-
tive state may be completely or partially related to the patient’s
disease, often an iatrogenic component can be identified. The
clinicians caring for the patient in this urgently life-threatening
state must be prepared to act swiftly and decisively to sustain or
recover oxygen saturation and ensure ventilation.
With these definitions in mind, it is important to realize that
identification of the difficult airway before manipulation is
crucial, and it is the key step in preparing for optimal patient
care and a safe outcome.15 Selection of airway equipment or
devices, techniques, and procedures all pivot on airway evalua-
tion. The literature provides strong evidence that specific strat-
egies and communication of these strategies with the airway
team facilitate management of the difficult airway. The Ameri-
can Society of Anesthesiologists (ASA) algorithm on the man-
agement of the difficult airway is an example of such a
collaborative effort and should act as a foundation for locally
developed institution-specific action strategies.16 Refer to the
differences between the 1993 and 2003 versions of the ASA
algorithm (Box 6-1).
When considering management options for the difficult
airway situation, the anesthesiologist and surgeon must give
Box 6-1.  DIFFERENCES BETWEEN THE 1993 AND
2003 AMERICAN SOCIETY OF ANESTHESIOLOGISTS
ALGORITHMS FOR MANAGEMENT OF THE
DIFFICULT AIRWAY
1. Difficult ventilation is now listed first under assessment of the
likelihood and clinical impact of basic management problems.
Also, in the same category, difficult tracheostomy was added.
2. To pursue actively opportunities to deliver supplemental oxygen
throughout the process of difficult airway management was added.
3. When considering the relative merits and feasibility of basic
management choices, awake intubation versus intubation attempts
after induction of anesthesia should now be considered first, before
nonsurgical techniques, as the initial approach to intubation.
4. The use of a laryngeal mask airway is incorporated into the
algorithm in the awake limb and after induction of the general
anesthesia limb in both emergency and nonemergency pathways
(either as a ventilator device or as a conduit for tracheal intubation).
5. One more intubation attempt was removed.
6. Rigid bronchoscope was added as an option for emergency
noninvasive ventilation.
From Hagberg CA, Benumof JL. The American Society of Anesthesiologists
Management of the Difficult Airway algorithm and explanation—analysis of
the algorithm. In Hagberg CA, ed. Benumof’s airway management, ed 2.
Philadelphia: Elsevier; 2006:236-251.
FIGURE 6-1.  A Hollinger laryngoscope is the most dependable scope for
direct laryngoscopy in management of the difficult airway. Both cuffed and
cuffless tubes may be passed through the scope, although size is limited to
a 5.0 cuffed endotracheal tube. If a larger tube is required, intubation over
an Eschmann stylet is possible.
consideration to aborting the planned procedure, waking the
patient, and reassessing airway management options before
proceeding. When this is not an option, the team must consider
alternative techniques for laryngoscopy such as the video-
assisted GlideScope (Verathon, Bothell, WA), placement of a
laryngeal mask airway (LMA) and intubation by fiberoptic
laryngoscopy with or without an Aintree catheter, or direct
laryngoscopy with an anterior commissure (Hollinger) laryngo-
scope and intubation through the laryngoscope.
Use of the LMA in the difficult-airway situation has increased
as equipment has evolved to facilitate intubation through the
LMA. The success of this device led to the introduction of the
intubating LMA (LMA Fastrach; Teleflex, Limerick, PA) into
clinical practice.17,18 Intubation can be accomplished by passing
the endotracheal tube (ETT) alone through the LMA (blind
technique) or by intubation over a fiberoptic bronchoscope
with or without an Aintree catheter placed over the broncho-
scope; this latter technique provides visualization of the intuba-
tion and can be combined with videoendoscopy. The addition
of the Aintree catheter facilitates intubation after removal of
the LMA, if this is required to proceed with surgery.
The Hollinger anterior commissure laryngoscope is the oto-
laryngologist’s most useful tool in difficult-airway management
and should be considered when all other techniques have failed.
This is particularly true for fixed laryngeal and subglottic lesions,
in which a small, cuffless ETT can be passed under direct visu-
alization. The Hollinger scope will accommodate a 5.0 or
smaller cuffed ETT, although the insufflation port may become
lodged in the barrel of the scope. This should be determined
before intubation. An Eschmann stylet may also be passed
through the laryngoscope, and the ETT is passed over the stylet,
which allows placement of a larger sized ETT (Fig. 6-1).
Awake fiberoptic intubation should always be considered as
a viable option, especially in the anticipated difficult airway situ-
ation. This technique is discussed in more detail in following
sections.
Surgical procedures such as open cricothyroidotomy, trache-
ostomy, and transtracheal jet ventilation must be considered
when faced with the cannot intubate/cannot ventilate situa-
tion. The role an otolaryngologist can play in such situations is
critical, and an otolaryngologist can provide expertise in endo-
scopic techniques with the ability to provide open surgical
access to the airway. The indications, contraindications, tech-
niques, and strategies to optimize success with these techniques
are discussed herein in detail.
88 PART II  |  GENERAL OTOLARYNGOLOGY

Box 6-2.  INDICATIONS FOR FIBEROPTIC INTUBATION

AWAKE FIBEROPTIC
NASOTRACHEAL INTUBATION
Awake fiberoptic nasotracheal intubation is now a common tech-
nique used in the management of the difficult airway in both  II. Compromised airway
the operating room (OR) and intensive care unit (ICU) settings.
HISTORIC PERSPECTIVE
Flexible fiberoptic technology has provided the vehicle for
developing and perfecting these intubation techniques. A flex-
ible fiberoptic choledochoscope was first used for nasotracheal
intubation on a patient with Stills disease as early as 1967.19 Five
years later, nasotracheal intubation was successfully carried out
in a patient with severe rheumatoid arthritis using a fiberoptic
bronchoscope (FOB).20 Stiles and colleagues21 subsequently
reported the first series of 100 fiberoptic endotracheal intuba-
tions. These intubations were performed both orally and
nasally, and the authors suggested that with experience, fiber-
optic intubation could be performed in less than 1 minute.
Davis22 described the use of FOB for checking the ETT posi-
tion in relation to the carina. Use of FOB to assess ETT position
was shown to be as good as chest radiography in both adults
and children.23,24 Many other uses of FOB technique were also
described, especially in critically ill patients, to evaluate the
upper and lower airway.25-28 Several authors cited advantages of
the technique, including the ability to perform diagnostic and
therapeutic procedures at the bedside without general anesthe-
sia and without interruption of ongoing mechanical ventila-
tion. Another advantage cited was the ability to perform the
procedure orally, nasally, or through an in situ ETT or trache-
ostomy tube. One main disadvantage reported by many authors
was the increased airway resistance, particularly in pediatric
patients, because the FOB may occupy a significant portion of
the lumen of the tube. FOB was not originally developed for
the management of the difficult intubation.29 However, as tech-
nology advanced and visualization improved, anesthesiologists
soon appreciated the value of the FOB in the management of
the difficult airway.30-32 Use of the FOB has been described for
airway management in Ludwig angina,33 rheumatoid arthritis,34
trauma,35 unstable cervical spine,36 disruptive injuries of the soft
tissue of the neck,37 acromegaly,38 and Pierre Robin syndrome,39
among other conditions. Several authors have reported success-
ful use of the FOB to secure the airway in awake patients with
increased risk of aspiration.40-43 As a result, the teaching of
fiberoptic airway endoscopy is now an integral part of training
for otolaryngology–head and neck surgery, anesthesiology, and
emergency medicine.
I. Difficult intubation
A. Known or anticipated
B. Unanticipated failed intubation
A. Upper airway
B. Lower airway (tracheal compression)
III. Intubation of the conscious patient preferred
A. High risk of aspiration
B. Movement of neck not desirable
C. Known difficult mask ventilation
D. Morbid obesity
E. Self-positioning
IV. High risk of dental damage
From Ovassapian A, Wheeler M. Fiberoptic endoscopy–aided techniques. In
Hagberg C, editor. Benumofand Hagberg’s airway management. St Louis:
Mosby; 1996:282-319.
BRONCHOSCOPY CART
Properly functioning equipment is essential to a successful
outcome. A fully equipped videobronchoscopy cart should be
available for use in the ICUs, emergency department, critical
care wards (e.g., otolaryngology patient floor), and in the OR.
All equipment and supplies for administration of anesthesia,
resuscitation, and monitoring should be available and should
be checked according to a standard protocol before beginning
a nonemergent FOI (Fig. 6-2). For awake intubations, the cart
is placed on the left side at the head of the bed, and a right-
handed operator stands on the right side facing the patient.
The light source should be checked for integrity, the necessary
supplies are laid out on top of the fiberoptic cart, and suction
is connected and at hand. The cart should contain ancillary
equipment that includes nasopharyngeal airway and endotra-
cheal tubes (standard and long microlaryngoscopy tubes)
among other items.
FIBEROPTIC INTUBATION OF
THE CONSCIOUS PATIENT
The advantages of awake FOI include maintenance of spontane-
ous ventilation and the ability to position the tip of the ETT
precisely beyond the obstruction/compression. It is easiest in
the awake, near-upright patient, because the tongue does not
fall back in the pharynx, and breathing tends to keep the airway

INDICATIONS
When the airway is compromised or a difficult airway is antici-
pated, awake fiberoptic intubation (FOI) with or without seda-
tion should be considered (Box 6-2). Awake FOI is an ideal
procedure for patients with morbid obesity, supraglottic mass,
or edema with the ability to visualize the glottic aperture; when
there is a risk of aspiration, a history of known DMV or prior
difficulty with transoral intubation using other techniques; and
in patients with limited mandible excursion or trismus. Contra-
indications to awake FOI include fixed stenotic lesions at all
levels that will not allow passage of an ETT without dilation,
active bleeding that obscures visualization, an acute obstructing
supraglottitis, and in patients unable to cooperate during the
examination. In general, many patients who might be denied
general anesthesia or who might receive a tracheostomy can be
safely intubated using the FOB. To intubate patients safely and FIGURE 6-2.  Cart for anesthesia for the difficult airway demonstrates orga-
quickly, certain preparatory steps should be taken. nization of ancillary items used for fiberoptic intubation.
 6  |  SURGICAL MANAGEMENT OF THE DIFFICULT ADULT AIRWAY 89
Box 6-3.  KEYS TO SUCCESSFUL AWAKE
FIBEROPTIC INTUBATION
I. Expert endoscopist
II. Functioning fiberoptic bronchoscope and supplies
III. Preparation of the patient
A. Psychologic preparation: informative, reassuring preoperative visit
B. Pharmacologic preparation
1. Premedication
a. Light or no sedation for calm patients
b. Heavy sedation for anxious patients
c. Narcotics when pain is present
d. Specific drugs for habitual drug users
e. Antisialagogues unless contraindicated
2. Intravenous sedation
a. No sedation for patients with severely compromised
airway
b. Conscious sedation for most patients
c. Heavy sedation for uncooperative patients
3. Topical anesthesia
a. Oral intubation: oropharynx, laryngotracheal
b. Nasal intubation: nasal mucosa, laryngotracheal
c. Monitoring and oxygen
Modified from Wheeler M, Ovassapian A. Fiberoptic endoscopy–aided
techniques. In Hagberg CA, ed: Benumof’s airway management, ed 2.
Philadelphia: Elsevier; 2006:399-438.
open. In addition, with deep inspiration, the patient can assist
the operator in locating the glottis when the airway anatomy is
distorted. Box 6-3 lists factors crucial to successful completion
of an awake FOI. These include training and preparation of the
airway team, psychologic and pharmacologic preparation of the
patient, appropriate monitoring and delivery of oxygen during
preparation of the patient and throughout the procedure,
expertise of the operator, and an adequate bronchoscopy cart.
PREPARING THE PATIENT
Psychologic Preparation
A successful outcome is more likely to occur with a relaxed and
cooperative patient. The preparation starts with an informative,
reassuring preoperative visit with the patient. The process is
explained in detail, and all the patient’s questions are answered.
If intubation is going to be performed without any sedation,
the reason—almost always patient safety—is explained. The
patient’s active participation is requested and may include
maintenance of head position, deep breathing, or clearing of
secretions when requested. When minimal or no sedation is
used, the patient should be informed that recall of the proce-
dure is possible.
Pharmacologic Preparation
The three components of the pharmacologic preparation of
the patient for awake FOI include 1) premedication, 2) limited
sedation at the time of intubation, and 3) application of topical
anesthesia. The goals of premedication include sedation that
augments the psychologic preparation and provision of an anti-
sialogogue to reduce secretions. Midazolam 1 to 3 mg intra-
muscularly or 10 to 20 mg by mouth provides adequate sedation
in most patients. If the patient’s airway or physical condition is
compromised, no sedative or opioid should be given before the
patient’s arrival at a monitored setting, where the airway team—
including an anesthesiologist—is in attendance. An antisialo-
gogue agent is essential for establishing good topical anesthesia
and to optimize conditions for fiberoptic visualization of the
glottis.44 Glycopyrrolate is considered the agent of choice in
that it does not cross the blood-brain barrier, and it causes less
tachycardia.
Monitoring
Standard monitoring is applied to all patients who undergo
FOB, whether the procedure is performed in the OR suite,
ICU, or any other location. Oxygen is provided by nasal cannula
at a flow rate of 3 L/min to all adult patients who undergo FOI
unless contraindicated.
Conscious Sedation
When possible, conscious sedation is administered in immedi-
ate preparation for intubation. The goal of conscious sedation
is to have a calm and cooperative patient who can follow verbal
commands and maintain adequate oxygenation and ventila-
tion. Depending on the indication for FOI, an opioid, a seda-
tive, or a combination of both is used. A combination of fentanyl
(1.5 µ/kg) and midazolam (30 µ/kg) has been used success-
fully for these procedures. Remifentanil infusion may also be
used for sedation for FOI.45,46 This approach may not be indi-
cated in the obese patient with obstructive sleep apnea, because
it may precipitate an airway crisis. Use of sedation should 
be discussed with the anesthesiologist before initiating the
procedure.
Topical Anesthesia
Instrumentation of the airway without using topical anesthesia
is uncomfortable and distressing to an awake patient. Pharma-
cologic preparation should, therefore, include application of
adequate topical anesthesia, which eliminates pharyngeal,
laryngeal, and tracheobronchial reflexes. Presence of excess
secretions dilutes the local anesthetic solution, creates a barrier
between the drug and the mucosa, and carries the local anes-
thetic away from the site of action.47,48 Therefore, use of an
effective antisialogogue is necessary. Furthermore, the absorp-
tion rate and amount of topical anesthetic vary according to
the site of application, the dose of the drug, and the general
condition of the patient.30,49,50 The agents are absorbed more
rapidly from alveoli than from the tracheobronchial tree, and
the rate and amount absorbed from the pharynx is even lower.
The dosage for topical agents should be halved when applying
them to the respiratory mucosa, because the plasma levels rise
more rapidly than do injections into the tissues.43
NASOTRACHEAL INTUBATION
OF THE AWAKE PATIENT
TOPICAL ANESTHESIA
The more patent nostril is selected and is sprayed with 2 mL 
of oxymetazoline. This should be determined in the clinic if
possible or just before the procedure by direct examination.
The cotton-tipped applicators are then soaked in 4% cocaine
(4 mL) and gently pasted over the septum and the inferior tur-
binates; alternatively, a combination of 4% lidocaine with 1%
phenylephrine may be used instead. It is advisable to wait at
least 5 minutes to allow maximal vasoconstriction and topical
anesthesia. Using cotton-tipped applicators helps evaluate the
patency of the nostril as well as to predict the angle of the nasal
floor, which slopes downward from front to back. Laryngotra-
cheal anesthesia is achieved by transtracheal injection of 1%
lidocaine or by spraying through the FOB during intubation.
The oropharynx should also be anesthetized, because the gag
reflex is stimulated by the nasal route. Using nebulized lido-
caine during set-up before the procedure is a useful technique.
TECHNIQUE
Intubating fiberoptically via the nasal route is easier than the
oral approach, because the scope is usually pointed straight at
90 PART II  |  GENERAL OTOLARYNGOLOGY
FIGURE 6-3.  Nasal trumpet placed for dilation is lubricated with
lidocaine gel.
the vocal cords as it enters the oropharynx and is generally
better tolerated by the patient.31 Our preferred method is to
prepare the nose as described above while setting up the equip-
ment and supplies. The ETT is placed in warm saline to soften
it. The cuff is tested by inflation, and to minimize resistance,
the cuff is retracted back when deflated so that it is flush with
the outer wall of the tube. The nasal passages are first dilated
to the appropriate diameter with increasingly larger nasal trum-
pets, which are generously lubricated with lidocaine gel and
epinephrine solution (Fig. 6-3). The ETT is then placed into
the nostril and directed downward, as it is advanced toward the
nasopharynx. If the tube does not make the bend toward  at this point, and continuous communication with the patient,
the oropharynx, it is pulled back and rotated 90 degrees to the
right or left and then reintroduced.
The FOB, which is connected to a videoendoscopy unit, is
then passed through the ETT and is used to visualize the airway
(Fig. 6-4). It is preferable to have the patient’s head elevated and,
if possible, to be sitting near upright to minimize airway collapse;
the operator faces the patient and the video monitor (Fig. 6-5).
The video-assisted FOI provides feedback to those assisting with
the procedure and facilitates intubation. In 80% to 85% of
patients, the epiglottis and vocal folds are seen with minimal or
FIGURE 6-4.  After placement of the endotracheal tube into the nasal cavity,
the fiberoptic bronchoscope is passed through the tube for visualization of
the airway.
FIGURE 6-5.  Optimal setup for fiberoptic intubation includes a patient with
the head elevated to minimize airway collapse, the operator facing patient,
and the entire team observing the procedure on the video monitor.
no manipulation of the tip of the scope. In patients who are not
breathing spontaneously or who are older, the tongue and pha-
ryngeal tissue may fall back and block the exposure of the larynx.
A few maneuvers help visualize the cords: these include extend-
ing the head, applying jaw thrust, or gently pulling the tongue
forward. Once visualized, application of 3-mL aliquots of 2%
lidocaine instilled through the scope should be performed at
the level of the vocal folds before intubation, and time should
be allowed for these to take effect. Patience is extremely helpful
letting him or her know that all is proceeding as planned, helps
minimize anxiety. It is also helpful to have multiple syringes with
“slip-tips” preloaded with lidocaine, because repeated injections
may be necessary, until the patient no longer coughs in response
to stimulation. The scope is then advanced through the vocal
folds. Timing the entry of the scope with the breathing cycle is
a useful trick. Once adequate visualization is achieved, the scope
is then advanced into the cervical trachea, and additional lido-
caine in instilled. The scope is then advanced to a level just above
the carina, and the ETT is passed over the scope into position.
If resistance is encountered during this maneuver, it is helpful
to rotate the ETT 90 degrees clockwise, changing the orientation
of the bevel.51
AVOIDING FAILURE IN FIBEROPTIC
AWAKE INTUBATION
CAUSES OF FAILURE
Lack of training and expertise in the use of fiberoptic bron-
choscopy is the single most common cause of failure in awake
FOIs. Other causes may be considered under the categories of
team factors, patient factors, and equipment issues. These are
outlined in Box 6-4.
PEARLS TO ENSURE SUCCESSFUL
AWAKE FIBEROPTIC INTUBATION
The training and expertise of the operator and the team is most
critical (see Box 6-3 for a list of keys for successful awake intuba-
tion). There is no substitute for structured training during resi-
dency or fellowship.30,32 Preparing the team and keeping the
communication lines open during the entire process helps
ensure successful intubation. Maintaining a fully stocked, easily
 6  |  SURGICAL MANAGEMENT OF THE DIFFICULT ADULT AIRWAY 91
Box 6-4.  CAUSES OF FAILURE OF FIBEROPTIC
INTUBATION
I. Team factors
A. Lack of expertise
B. Poor topical anesthesia
II. Patient factors
A. Suboptimally prepared patient
B. Presence of secretions and blood
C. Decreased space between epiglottis and posterior pharyngeal wall
D. Distorted airway anatomy
III. Equipment factors
A. Fogging of the objective and focusing lenses
B. Passage of the fiberoptic bronchoscope through the Murphy eye
C. Inadequate lubrication of a tightly fitting fiberoptic
bronchoscope
Modified from Wheeler M, Ovassapian A. Fiberoptic endoscopy–aided
techniques. In Hagberg CA, ed: Benumof’s airway management, ed 2.
St Louis: Elsevier; 2006:399-438.
transportable, and functioning FOB cart at hand is highly desir-
able as well.
Psychologic and pharmacologic preparation of the patient
increases the likelihood of a successful outcome. It is essential
to administer an adequate dose of an antisialogogue, a sedative
if indicated, and topical anesthesia. The value of proper suc-
tioning before an intubation attempt cannot be overempha-
sized. The conscious patient can be asked to swallow and cough
to clear secretions. In some patients, the tip of the epiglottis
may fall against the posterior pharyngeal wall and can interfere
with navigation of the scope into the larynx. Application of a
jaw thrust or a gentle but firm pull on the tongue moves the
epiglottis away from the posterior pharyngeal wall and corrects
the problem.
Advancing the ETT into the trachea is not possible when the
FOB is passed through the Murphy eye of the ETT rather than
through the distal opening.52 Withdrawal of the FOB may be
difficult or impossible without damaging the instrument. The
scope and the tube should be withdrawn as a unit, the scope
disengaged, and the procedure repeated. It is also necessary to
use lubrication on the scope to facilitate movement of the tube
into and out of the ETT.53
OPERATIVE SURGICAL
AIRWAY OPTIONS
HISTORIC PERSPECTIVES
The role of the surgical airway as a lifesaving procedure has
been appreciated for thousands of years.54 Egyptian tablets that
date back to 3600 bce depict surgical tracheostomy.55 In the
second century ce, Galen described a tracheostomy using a
vertical incision as an emergency measure for airway obstruc-
tion.56 The first detailed description of tracheostomy was pub-
lished in the sixteenth century by Vesalius, who proposed using
the procedure to ventilate the lungs. The Spanish Inquisition,
however, condemned his alleged resuscitation of a Spanish
nobleman.57
The first recording of a successful tracheostomy in the
United States was in 1852. The patient later died of airway
stenosis, which remained a common complication of the pro-
cedure for decades to follow. A mortality rate of 50% was
quoted for tracheostomy in an 1886 paper, and many of these
deaths were attributed to a high incidence of stenosis.58 A land-
mark paper by Chevalier Jackson59 in 1909 described a safe
surgical technique and principles that are still applicable. He
described many factors that he considered to contribute to a
lower mortality rate (3% at the time). These included optimal
securing of the airway before the procedure, the use of local
anesthesia instead of sedation, using a specifically designed
tube, and meticulous surgical technique and postoperative
care. In the same paper, Jackson condemned the technique of
high tracheostomy, the term used for cricothyrotomy at the time.
In a later paper in 1921, Jackson60 described his series of 200
patients referred to him who had postcricothyrotomy stenosis.
In addition to the obvious referral bias, the primary indication
at the time, inflammatory lesions of the upper airway, might
have accounted for the high incidence of subglottic stenosis.
After Jackson’s criticism, cricothyrotomy continued to be
condemned for more than half a century. It was not until 
Brantigan and Grow61 published a series of 655 patients who
underwent cricothyrotomy for chronic airway management
that this changed. They described a procedure that was faster,
simpler, and less likely to cause bleeding than tracheostomy.
The stenosis rate was 0.01%, and no major complications were
reported. Many subsequent studies support their conclusion
that cricothyrotomy is a safe and effective surgical procedure
and is in fact preferable to tracheostomy for emergent airway
control.62
CRICOTHYROTOMY
DEFINITION
Cricothyrotomy is the establishment of a surgical opening into the
airway through the cricothyroid membrane (CTM) and place-
ment of a tube for ventilation.54 It differs from tracheostomy in
the anatomic location of the entry into the airway.
ANATOMIC CONSIDERATIONS
In emergent situations, cricothyrotomy is preferable to trache-
ostomy because of relative simplicity, speed, and a lower peri-
operative complication rate. The airway at the level of the CTM
is separated from the skin only by the subcutaneous fat, ante-
rior cervical fascia, and strap muscles laterally. The trachea
moves progressively deeper in the neck as it moves caudally,
which makes anterior access more difficult. Additionally, the
thyroid isthmus overlies the second to fourth tracheal rings and
acts as an additional structure to negotiate when performing a
tracheostomy.
CRICOTHYROID MEMBRANE
The CTM stretches between the thyroid cartilage and the
cricoid ring and consists of fibroelastic tissue. In an average
adult male, it is 1 cm high and 2 to 3 cm wide, located in the
midline about a fingerbreadth below the laryngeal promi-
nence. The vocal folds are approximately 1 cm above the CTM
and are therefore prone to injury during a cricothyrotomy. The
ligament does not calcify with age, and it has no overlying
muscles, major vessels, or nerves; however, the anterior jugular
veins border the membrane laterally, and bleeding from these
vessels may be substantial.
The right and left cricothyroid arteries are branches of the
right and left superior thyroid arteries. In most patients these
vessels cross the superior aspect of the CTM to anastomose in
the midline.63 Although at risk for injury during cricothyrot-
omy, the resulting bleeding is usually self-limiting and easily
controlled with gauze packing.
The CTM lies a fingerbreadth below the laryngeal promi-
nence. Its location can also be estimated to be 3 to 4 finger-
breadths above the suprasternal notch with the neck in a
neutral position, although this may be quite variable depending
on body habitus. Identification of the landmarks may be diffi-
cult or impossible in the edematous or traumatized neck and
in obese patients.
92 PART II  |  GENERAL OTOLARYNGOLOGY

SURGICAL CRICOTHYROTOMY
Indications
The primary indication for cricothyrotomy is failure to intubate
by oral or nasal means in the presence of an immediate need
for definitive airway management and an inability to mask ven-
tilate the patient.
The ASA Difficult Airway Algorithm recommends a surgical
airway as the final end point for the unsuccessful arm of the
emergency pathway.64 Despite the introduction of numerous
rescue devices for failed airway, the most common errors in the CTM
management of the difficult airway result from repeated unsuc-
cessful attempts at intubation in these situations.65 Once the
cannot intubate/cannot ventilate situation has been identified, immedi-
ate consideration should be given to a surgical airway. Failure to
pursue this approach when unable to ventilate will most likely
result in a delay in achieving airway control, which places the FIGURE 6-6.  With the superior cornu of the larynx firmly immobilized by
patient at risk for subsequent hypoxic brain injury and/or the thumb and long finger of the operator’s nondominant hand, the index
death. Often the main obstacle is lack of experience or timely finger is free to palpate and locate the cricothyroid membrane (CTM). (From
recognition of the need to perform this procedure. Adequate Walls RM, Murphy MF, Luten RC, et al. Manual of emergency airway management,
training in the laboratory, planning based on an algorithm and ed 2. Philadelphia: Lippincott Williams & Wilkins; 2004.)
availability of equipment, and trained personnel are the keys to
successful performance of the procedure. Availability of neces- of the thyroid cartilage (Fig. 6-11) to facilitate elevating and
sary equipment, preferably packaged as a preassembled kit, opening the airway. A small (5.0) endotracheal tube or a tra-
prevents wasting crucial minutes gathering supplies in an emer- cheostomy tube is then placed and secured in position (Fig.
gency situation (Box 6-5). 6-12). After stabilizing the patient, the cricothyrotomy should
Relative contraindications for cricothyrotomy include age be converted to a formal tracheostomy, preferably in the OR,
younger than 10 years, severe neck trauma with inability to if long-term intubation is anticipated. If early extubation is
palpate the landmarks, and expanding neck hematoma. Preex- anticipated, the cricothyrotomy may be used until extubation.
isting laryngeal disease with subglottic extension (e.g., malig- See Hsiao J & Pacheco-Fowler68 for the basic technique of
nancy) is another relative contraindication. A planned, urgent cricothyrotomy.
awake tracheostomy is preferred in this situation. Emergency
or “slash” tracheostomy is a procedure that carries a very high Rapid Five-Step Technique
risk of complications, up to five times that of an elective A rapid four-step technique has been described and is reported
procedure.66 to be simple to learn and faster in obtaining a surgical airway.69
This technique has many advantages that include 1) the need
Surgical Procedure for less equipment, 2) the need for only one operator without
Identification and palpation of the sternal notch; the thyroid assistance, and 3) the positioning is such that the operator
cartilage, especially the superior thyroid notch; and cricoid stands at the patient’s head.54 The authors prefer a slight modi-
cartilage, felt as an indentation below the thyroid cartilage, is fication and use a five-step rule:
the critical first step in a cricothyrotomy (Fig. 6-6). Stabilization 1. Identify landmarks and stabilize the airway.
of the upper airway with the operator’s nondominant hand 2. Make a vertical skin incision.
during the rest of the procedure is the single most important 3. Make a horizontal incision through the cricothyroid
factor in determining successful outcome.67 This technique membrane.
pins the larynx in the midline and facilitates dissection by 4. Insert a clamp to spread and elevate the airway.
maintaining anatomic positioning of the airway. 5. Insert a tracheostomy tube or small ETT.
A midline vertical skin incision over the cricoid cartilage
avoids the often engorged anterior jugular veins and minimizes
the risk of injury to the carotid arteries and jugular veins (Fig.
6-7). The membrane is palpated through the incision (Fig. 6-8)
and is entered with a horizontal incision at the lower edge of
the cricothyroid space (Fig. 6-9). This incision is then dilated
with a hemostat or Kelly clamp placed in the airway and is
opened horizontally while lifting upward to expose the opening
(Fig. 6-10). A cricoid hook may be placed at the inferior edge

Box 6-5.  EQUIPMENT FOR EMERGENCY SURGICAL

CRICOTHYROTOMY
No. 15 blade
Crile forceps or hemostats
Small endotracheal tube (5.0) or a tracheostomy tube (size 4 cuffed)
Cricoid hook (single curved hook)
Scissors FIGURE 6-7.  A vertical skin incision is made down to, but not through, the
Tracheal dilator airway. (From Walls RM, Murphy MF, Luten RC, et al. Manual of emergency airway
management, ed 2. Philadelphia: Lippincott Williams & Wilkins; 2004.)
 6  |  SURGICAL MANAGEMENT OF THE DIFFICULT ADULT AIRWAY 93

FIGURE 6-10.  The Trousseau dilator is used to enlarge the vertical dimen-
sion of the membrane, the aspect that provides the most resistance to
insertion of the tube. (From Hagberg CA, editor. Benumof’s airway management,
ed 2. Philadelphia: Elsevier; 2006.)

FIGURE 6-8.  The index finger is used to directly palpate and relocate the
cricothyroid membrane. (From Walls RM, Murphy MF, Luten RC, et al. Manual
of emergency airway management, ed 2. Philadelphia: Lippincott Williams &
Wilkins; 2004.)

The incidence of complications reported after cricothyrot-

omy varies from 6% to 39% depending on whether the proce-
dure was done semielectively or as an emergent procedure.
Reported complications include bleeding, trauma, or injury to
the laryngeal framework and/or vocal folds (Fig. 6-13), medi-
astinal emphysema, pneumothorax, false passage with the tube
placed in the mediastinum, esophageal laceration, and failure
to secure the airway.

FIGURE 6-11.  The tracheal hook exerts light traction on the inferior aspect
of the thyroid cartilage. (From Hagberg CA, editor. Benumof’s airway manage-
ment, ed 2. Philadelphia: Elsevier; 2006.)

FIGURE 6-9.  A transverse incision is made in the cricothyroid membrane,

staying low to attempt to avoid the cricothyroid artery and vein. (From FIGURE 6-12.  The tracheostomy tube is inserted, and then the dilator can
Hagberg CA, ed. Benumof’s airway management, ed 2. Philadelphia: Elsevier; be rotated counterclockwise 90 degrees. (From Hagberg C, editor. Benumof’s
2006.) airway management, ed 2. Philadelphia: Elsevier; 2006.)
94 PART II  |  GENERAL OTOLARYNGOLOGY
FIGURE 6-13.  Cricoid cartilage shown split in the midline following emer-
gency cricothyrotomy. The site was repaired at the time of revision to formal
tracheotomy.
PERCUTANEOUS CRICOTHYROTOMY
Primarily based on a modified Seldinger technique, many com-
mercially available kits and systems can help place a tracheal
airway with limited surgical dissection beyond the skin incision.
Although deemed simpler than a surgical technique by many
nonsurgeons, the procedure increases complexity and requires
execution of more than five steps to secure an airway. Although
no significant differences in performance times between open
surgical cricothyrotomy and the percutaneous procedure have
been noted in cadaver and dog models, as with the open crico-
thyrotomy, severe complications are more likely to occur in
emergent situations.70,71 One of the limitations of percutaneous
cricothyrotomy, especially with the commercially available kits,
is the relatively small lumen of the cannula.72
In general, percutaneous tracheotomy is considered an elec-
tive procedure and should not be considered for emergency
airway scenarios.
TRANSTRACHEAL NEEDLE
VENTILATION
Transtracheal needle ventilation can be used as a great option
to buy time in an emergency. Access to the equipment, includ-
ing 100% oxygen at 50 psi, a large-bore needle and cannula
(14 gauge), and a Luer-Lock connector is all that is required.
The airway is accessed by puncturing the trachea or the CTM
with a small saline-filled syringe attached to the needle-cannula
combination. It is advanced through the skin in the midline in
a 30-degree caudal direction. Upon confirming entrance into
the airway by the presence of bubbles in the saline-filled syringe,
the cannula is advanced while withdrawing the needle. The
cannula is then connected to the oxygen with the Luer-Lock
connector and a manual interrupter switch. The patient can
only be oxygenated with this technique for 30 minutes to 2
hours, because this type of ventilation is suboptimal.
Complications associated with this procedure are similar to
those in cricothyrotomy and include an improperly placed 
catheter and mediastinal emphysema, pneumothorax, hema-
toma, and kinking of the catheter with an inability to adequately
oxygenate or ventilate the patient. Similar to percutaneous
cricothyrotomy, I prefer to use this technique in elective or
semiurgent situations only.
CONCLUSION
It is my belief that difficult airway management is an emerging
subspecialty within otolaryngology–head and neck surgery. The
nature of these situations demands a multidisciplinary effort to
standardize institutional action plans and strategies for training
along with day-to-day management of these patients that capi-
talizes on the skills provided by experienced anesthesiologists,
otolaryngology–head and neck surgeons, general surgeons,
emergency department physicians, respiratory therapists, and
nursing staff.
ACKNOWLEDGMENT
I thank Dr. Kulsoom Laeeq, MD, for her help with editing the
manuscript for this chapter.
For a complete list of references, see expertconsult.com. 
SUGGESTED READINGS
Benumof JL, Scheller MS: The importance of transtracheal jet ventila-
tion in the management of difficult airway. Anesthesiology 71:769,
1989.
Brofeldt BT, Panacek EA, Richards JR: An easy cricothyrotomy
approach: the rapid four-step technique. Acad Emerg Med 3(11):1060–
1063, 1996.
Caplan RA, Posner KL, Ward RJ, et al: Adverse respiratory events in
anesthesia: a closed claim analysis. Anesthesiology 72:828, 1990.
Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics. Anaes-
thesia 39(11):1105–1111, 1984.
Edens ET, Sia RL: Flexible fiberoptic endoscopy in difficult intubations.
Ann Otol Rhinol Laryngol 90(4 Pt 1):307–309, 1981.
Fasting S, Gisvold SE: Serious intraoperative problems—a five year
review of 83,844 anesthetics. Can J Anaesth 49:545, 2002.
Gibbs MA, Walls RM: Surgical airway. In Hagberg CA, editor: Benumof’s
airway management, ed 2, Philadelphia, 2006, Elsevier, pp 678–696.
Hagberg CA, Benumof JL: The American Society of Anesthesiologist’s
Management of the Difficult Airway Algorithm and explanation—
analysis of the algorithm. In Hagberg CA, editor: Benumof’s airway
management, ed 2, Philadelphia, 2006, Elsevier, pp 236–251.
Holmes JF, Panacek EA, Sakles JC, et al: Comparison of 2 cricothyrot-
omy techniques: standard method versus rapid 4-step technique. Ann
Emerg Med 32(4):442–446, 1998.
Hsiao J, Pacheco-Fowler V: Videos in clinical medicine. Cricothyroid-
otomy. N Engl J Med 358(22):e25, 2008.
Jackson C: High tracheostomy and other errors: the chief cause of
chronic laryngeal stenosis. Surg Gynecol Obstet 32:392, 1921.
Klock PA, Benumof JL: Definition and incidence of the difficult airway.
In Hagberg CA, editor: Benumof’s airway management, ed 2, Philadel-
phia, 2006, Elsevier, pp 215–220.
Langeron O, Masso E, Huraux C, et al: Prediction of difficult mask
ventilation. Anesthesiology 92(5):1229–1236, 2000.
Ovassapian A, Yelich SJ, Dykes MH, et al: Fiberoptic nasotracheal
intubation—incidence and causes of failure. Anesth Analg 62(7):692–
695, 1983.
Practice guidelines for management of the difficult airway: an updated
report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology 98(5):1269–1277,
2003.
Rehm CG, Wanek SM, Gagnon EB, et al: Cricothyroidotomy for elective
airway management in critically ill trauma patients with technically
challenging neck anatomy. Crit Care 6(6):531–535, 2002.
Schwartz HC, Bauer RA, Davis NJ, et al: Ludwig’s angina: use of fiber-
optic laryngoscopy to avoid tracheostomy. J Oral Surg 32(8):608–611,
1974.
Wilson ME, Spiegelhalter D, Robertson JA, et al: Predicting difficult
intubation. Br J Anaesth 61(2):211–216, 1988.
 6  |  SURGICAL MANAGEMENT OF THE DIFFICULT ADULT AIRWAY 94.e1
REFERENCES
1. Caplan RA, Posner KL, Ward RJ, et al: Adverse respiratory  692–695, 1983.
events in anesthesia: a closed claim analysis. Anesthesiology 72:828,
1990.
2. Fasting S, Gisvold SE: Serious intraoperative problems—a five year
review of 83,844 anesthetics. Can J Anaesth 49:545, 2002.
3. Benumof JL, Scheller MS: The importance of transtracheal jet
ventilation in the management of difficult airway. Anesthesiology 71:
769, 1989.
4. Klock PA, Benumof JL: Definition and incidence of the difficult
airway. In Hagberg CA, editor: Benumof’s Airway Management, ed 2,
Philadelphia, 2006, Elsevier, pp 215–220.
5. Mallampati SR, Gatt SP, Gugino LD, et al: A clinical sign to predict
difficult tracheal intubation: a prospective study. Can Anaesth Soc J
32(4):429–434, 1985.
6. Samsoon GL, Young JR: Difficult tracheal intubation: a retrospec-
tive study. Anaesthesia 42(5):487–490, 1987.
7. Cormack RS, Lehane J: Difficult tracheal intubation in obstetrics.
Anaesthesia 39(11):1105–1111, 1984.
8. Wilson ME, Spiegelhalter D, Robertson JA, et al: Predicting diffi-
cult intubation. Br J Anaesth 61(2):211–216, 1988.
9. Finucane BT, Santora AH: Difficult Intubation, ed 2, St Louis, 1996,
Mosby–Year Book, p 187.
10. Rose DK, Cohen MM: The airway: problems and predictions in
18,500 patients. Can J Anaesth 41(5 Pt 1):372–383, 1994.
11. Williams KN, Carli F, Cormack RS: Unexpected, difficult laryngos-
copy: a prospective survey in routine general surgery. Br J Anaesth
66(1):38–44, 1991.
12. Langeron O, Masso E, Huraux C, et al: Prediction of difficult mask
ventilation. Anesthesiology 92(5):1229–1236, 2000.
13. Eichhorn JH: Documenting improved anesthesia outcome. J Clin
Anesth 3(5):351–353, 1991.
14. Keenan RL, Boyan CP: Decreasing frequency of anesthetic cardiac
arrests. J Clin Anesth 3(5):354–357, 1991.
15. Cass NM, James NR, Lines V: Difficult direct laryngoscopy compli-
cating intubation for anaesthesia. BMJ 1(4965):488–489, 1956.
16. Hagberg CA, Benumof JL: The American Society of Anesthesiolo-
gist’s management of the difficult airway algorithm and
explanation—analysis of the algorithm. In Hagberg CA, editor:
Benumof’s Airway Management, ed 2, Philadelphia, 2006, Elsevier,
pp 236–251.
17. Benumof JL: Laryngeal mask airway and the ASA difficult airway
algorithm. Anesthesiology 84(3):686–699, 1996.
18. Brain AI, Verghese C, Addy EV, et al: The intubating laryngeal
mask. I: Development of a new device for intubation of the trachea.
Br J Anaesth 79(6):699–703, 1997.
19. Murphy P: A fibre-optic endoscope used for nasal intubation.
Anaesthesia 22(3):489–491, 1967.
20. Conyers AB, Wallace DH, Mulder DS: Use of the fiber optic bron-
choscope for nasotracheal intubation: case report. Can Anaesth
Soc J 19(6):654–656, 1972.
21. Stiles CM, Stiles QR, Denson JS: A flexible fiber optic laryngoscope.
JAMA 221(11):1246–1247, 1972.
22. Davis NJ: A new fiberoptic laryngoscope for nasal intubation.
Anesth Analg 52(5):807–808, 1973.
23. Dietrich KA, Strauss RH, Cabalka AK, et al: Use of flexible fiber-
optic endoscopy for determination of endotracheal tube position
in the pediatric patient. Crit Care Med 16(9):884–887, 1988.
24. O’Brien D, Curran J, Conroy J, et al: Fibre-optic assessment of
tracheal tube position. A comparison of tracheal tube position as
estimated by fibre-optic bronchoscopy and by chest X-ray. Anaesthe-
sia 40(1):73–76, 1985.
25. Fan LL, Flynn JW: Laryngoscopy in neonates and infants: experi-
ence with the flexible fiberoptic bronchoscope. Laryngoscope 91(3):
451–456, 1981.
26. Fan LL, Sparks LM, Dulinski JP: Applications of an ultrathin flex-
ible bronchoscope for neonatal and pediatric airway problems.
Chest 89(5):673–676, 1986.
27. Lindholm CE, Ollman B, Snyder JV, et al: Cardiorespiratory effects
of flexible fiberoptic bronchoscopy in critically ill patients. Chest
74(4):362–368, 1978.
28. Olopade CO, Prakash UB: Bronchoscopy in the critical-care unit.
Mayo Clin Proc 64(10):1255–1263, 1989.
29. Ikeda S: Atlas of Flexible Bronchofiberoscopy, Baltimore, 1974, Univer-
sity Park.
30. Ovassapian A, Yelich SJ, Dykes MH, et al: Fiberoptic nasotracheal
intubation—incidence and causes of failure. Anesth Analg 62(7):
31. Ovassapian A, Yelich SJ, Dykes MH, et al: Blood pressure and heart
rate changes during awake fiberoptic nasotracheal intubation.
Anesth Analg 62(10):951–954, 1983.
32. Ovassapian A, Dykes MH, Golmon ME: A training programme for
fibreoptic nasotracheal intubation. Use of model and live patients.
Anaesthesia 38(8):795–798, 1983.
33. Schwartz HC, Bauer RA, Davis NJ, et al: Ludwig’s angina: use of
fiberoptic laryngoscopy to avoid tracheostomy. J Oral Surg
32(8):608–611, 1974.
34. Rogers SN, Benumof JL: New and easy techniques for fiberoptic
endoscopy-aided tracheal intubation. Anesthesiology 59(6):569–572,
1983.
35. Mulder DS, Wallace DH, Woolhouse FM: The use of the fiberoptic
bronchoscope to facilitate endotracheal intubation following head
and neck trauma. J Trauma 15(8):638–640, 1975.
36. Sidhu VS, Whitehead EM, Ainsworth QP, et al: A technique of
awake fibreoptic intubation. Experience in patients with cervical
spine disease. Anaesthesia 48(10):910–913, 1993.
37. Davies JR: The fibreoptic laryngoscope in the management of cut
throat injuries. Br J Anaesth 50(5):511–514, 1978.
38. Ovassapian A, Doka JC, Romsa DE: Acromegaly—use of fiberoptic
laryngoscopy to avoid tracheostomy. Anesthesiology 54(5):429–430,
1981.
39. Scheller JG, Schulman SR: Fiber-optic bronchoscopic guidance for
intubating a neonate with Pierre Robin syndrome. J Clin Anesth
3(1):45–47, 1991.
40. Edens ET, Sia RL: Flexible fiberoptic endoscopy in difficult intuba-
tions. Ann Otol Rhinol Laryngol 90(4 Pt 1):307–309, 1981.
41. Keenan MA, Stiles CM, Kaufman RL: Acquired laryngeal deviation
associated with cervical spine disease in erosive polyarticular arthri-
tis. Use of the fiberoptic bronchoscope in rheumatoid disease.
Anesthesiology 58(5):441–449, 1983.
42. Nakayama M, Kataoka N, Usui Y, et al: Techniques of nasotracheal
intubation with the fiberoptic bronchoscope. J Emerg Med 10(6):
729–734, 1992.
43. Wheeler M, Ovassapian A: Fiberoptic endoscopy–aided techniques.
In Hagberg CA, editor: Benumof’s Airway Management, ed 2,
Philadelphia, 2006, Elsevier, pp 399–438.
44. Bowes WA, III, Johnson JO: Pneumomediastinum after planned
retrograde fiberoptic intubation. Anesth Analg 78(4):795–797,
1994.
45. Puchner W, Obwegeser J, Puhringer FK: Use of remifentanil for
awake fiberoptic intubation in a morbidly obese patient with severe
inflammation of the neck. Acta Anaesthesiol Scand 46(4):473–476,
2002.
46. Puchner W, Egger P, Puhringer F, et al: Evaluation of remifentanil
as single drug for awake fiberoptic intubation. Acta Anaesthesiol
Scand 46(4):350–354, 2002.
47. Reed AP, Han DG: Preparation of the patient for awake fiberoptic
intubation. Anesth Clin North Am 9:69, 1991.
48. Ovassapian A, Wheeler M: Fiberoptic Endoscopy-Aided Techniques.
Benumof’s Management: Principles and Practice, ed 1, St Louis, 1996,
Mosby, pp 282–319.
49. Patterson JR, Blaschke TF, Hunt KK, et al: Lidocaine blood con-
centrations during fiberoptic bronchoscopy. Am Rev Respir Dis
112(1):53–57, 1975.
50. Bourke DL, Katz J, Tonneson A: Nebulized anesthesia for awake
endotracheal intubation. Anesthesiology 63(6):690–692, 1985.
51. Katsnelson T, Frost EA, Farcon E, et al: When the endotracheal
tube will not pass over the flexible fiberoptic bronchoscope. Anes-
thesiology 76(1):151–152, 1992.
52. Ovassapian A: Failure to withdraw flexible fiberoptic laryngoscope
after nasotracheal intubation. Anesthesiology 63(1):124–125, 1985.
53. Siegel M, Coleprate P: Complication of fiberoptic bronchoscope.
Anesthesiology 61(2):214–215, 1984.
54. Mace SE: Cricothyrotomy. J Emerg Med 6:309–319, 1988.
55. Mace SE: Blunt laryngotracheal trauma. Ann Emerg Med 15(7):836–
842, 1986.
56. Boyle MF, Hatton D, Sheets C: Surgical cricothyrotomy performed
by air ambulance flight nurses: a 5-year experience. J Emerg Med
11(1):41–45, 1993.
57. Morain WD: Cricothyroidostomy in head and neck surgery. Plast
Reconstr Surg 65(4):424–428, 1980.
94.e2 PART II  |  GENERAL OTOLARYNGOLOGY
58. Ciaglia P, Firsching R, Syniec C: Elective percutaneous dilatational
tracheostomy. A new simple bedside procedure; preliminary
report. Chest 87(6):715–719, 1985.
59. Jackson C: Tracheotomy. Laryngoscope 18:285, 1909.
60. Jackson C: High tracheostomy and other errors: the chief cause of
chronic laryngeal stenosis. Surg Gynecol Obstet 32:392, 1921.
61. Brantigan CO, Grow JB, Sr: Cricothyroidotomy: elective use in
respiratory problems requiring tracheotomy. J Thorac Cardiovasc
Surg 71(1):72–81, 1976.
62. Gillespie MB, Eisele DW: Outcomes of emergency surgical airway
procedures in a hospital-wide setting. Laryngoscope 109(11):1766–
1769, 1999.
63. Leibovici D, Fredman B, Gofrit ON, et al: Prehospital cricothyroid-
otomy by physicians. Am J Emerg Med 15(1):91–93, 1997.
64. Practice guidelines for management of the difficult airway: an
updated report by the American Society of Anesthesiologists Task
Force on Management of the Difficult Airway. Anesthesiology 98(5):
1269–1277, 2003.
65. Rehm CG, Wanek SM, Gagnon EB, et al: Cricothyroidotomy  Benumof’s Airway Management, ed 2, Philadelphia, 2009, Elsevier,
for elective airway management in critically ill trauma patients  pp 678–696.
with technically challenging neck anatomy. Crit Care 6(6):531–535,
2002.
66. Goldenberg D, Ari EG, Golz A: Tracheotomy complications: a ret-
rospective study of 1130 cases. Otolaryngol Head Neck Surg 123:495–
500, 2000.
67. DiGiacomo C, Neshat KK, Angus LD, et al: Emergency cricothy-
rotomy. Mil Med 168:541–544, 2003.
68. Hsiao J, Pacheco-Fowler V: Videos in clinical medicine. Cricothy-
roidotomy. N Engl J Med 358(22):e25, 2008.
69. Holmes JF, Panacek EA, Sakles JC, et al: Comparison of 2 cricothy-
rotomy techniques: standard method versus rapid 4-step tech-
nique. Ann Emerg Med 32(4):442–446, 1998.
70. Bainton CR: Cricothyrotomy. Int Anesthesiol Clin 32(4):95–108,
1994.
71. Brofeldt BT, Panacek EA, Richards JR: An easy cricothyrotomy
approach: the rapid four-step technique. Acad Emerg Med
3(11):1060–1063, 1996.
72. Gibbs MA, Walls R: Surgical airway. In Hagberg CA, editor: