Retrograde Intubation in a Challenging Airway Scenario: A Case Report

Retrograde intubation is a valuable technique for airway management in situations where conventional intubation is difficult or when fiber-optic bronchoscopy is unavailable. It involves introducing a guidewire through the cricothyroid membrane and retrieving it via the mouth or nostril to facilitate endotracheal tube placement. Initially described by Butler and Cirillo in 1960 and refined by Waters in 1963, it remains a practical option in select clinical scenarios. This case report describes a 35-year-old male with carcinoma of the buccal mucosa involving the gingivobuccal sulcus and retromolar trigone, who had a 15-year history of tobacco chewing. He was scheduled for commando surgery with a pectoralis major myocutaneous flap. Airway assessment revealed restricted mouth opening (0.5 cm), Mallampati grade IV, and patent nostrils, rendering standard oral intubation unfeasible. Under mild sedation, retrograde intubation was planned. An 18G Tuohy needle was inserted through the cricothyroid membrane, and a soft-tip ureteric guidewire was passed and retrieved through the nostril. A 7.0 mm cuffed flexometallic endotracheal tube was threaded over the guidewire. Successful placement was confirmed by capnography and chest auscultation. The patient remained stable and cooperative throughout the procedure and was extubated uneventfully the following day. This case highlights retrograde intubation as an effective and safe alternative for managing anticipated difficult airways when other advanced tools are unavailable.