An adverse airway reaction during awake intubation in a patient with fibrodysplasia ossificans progressiva: A case report

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disorder characterized by the progressive heterotopic ossification (HO) of soft tissues. Anesthesia in patients with FOP is uniquely challenging due to airway abnormalities, severe anatomical restrictions, and the risk of trauma-induced ossification, particularly during airway manipulation. We describe the anesthetic management of a 22-year-old male with FOP undergoing elective odontectomy. Awake fiberoptic nasotracheal intubation under topical anesthesia was planned in accordance with standard recommendations. However, shortly after 10 % lidocaine spray to the nasal passages and oropharynx, the patient developed hypersalivation and intense coughing, consistent with an irritant-induced airway response, which led to significant agitation and rendered the awake technique intolerable. Sedation was adjusted using remifentanil target-controlled infusion and intravenous midazolam, while preserving spontaneous ventilation. Intubation was successful on the second attempt. Rocuronium was administered after tube placement. All airway management decisions aimed to avert airway compromise—especially critical in FOP, where anatomical restrictions and the risk of trauma-induced HO severely limit rescue options. Surgery and recovery were uneventful. This case highlights the need for individualized, flexible anesthetic strategies in FOP. While awake fiberoptic intubation is the gold standard, airway reactions—potentially exacerbated by the sensory hyperexcitability seen in FOP—can occur. Familiar agents with rapid onset/offset and reversible effects, such as remifentanil, may provide effective alternatives when the awake approach fails. Preparedness, atraumatic technique, and real-time adaptability are essential when managing anatomically complex and high-risk patients such as those with FOP.