A Case of a Vanished Nose and an Innovative Airway Management Strategy in Post-oncologic Nasal Defect Using Nasopharyngeal Airway

Basal cell carcinoma of the nose, when destructive, presents unique reconstructive and airway challenges due to its locally aggressive nature. We report a case of a 68-year-old male who presented with an extensive nasal defect from untreated basal cell carcinoma, requiring complete nasal reconstruction with radial free flap, and flap defect covered with anterolateral thigh graft. Anticipating a difficult airway following flap placement, we implemented a novel strategy: bilateral nasopharyngeal airways were inserted intraoperatively through surgically created openings in the flap. This approach maintained nasal patency, preserved flap integrity, and eliminated the need for a tracheostomy. The patient had a difficult airway due to limited mouth opening and distorted nasal anatomy. Awake oral fiberoptic intubation was successfully performed. The nasopharyngeal airway was sized to two-thirds of the standard length and secured through the flap with careful suturing to prevent displacement and pressure necrosis. During the postoperative period, humidified oxygen and saline irrigation were employed to avoid crusting and maintain airway hygiene. The nasopharyngeal airways remained in situ for four weeks without complications, until normal nasal passages were established. This case highlights the importance of multidisciplinary surgery, anesthesia, and airway planning, and introduces a minimally invasive technique that achieves both functional and structural outcomes in complex nasal reconstructions. To our knowledge, prolonged bilateral nasopharyngeal airway use through a free flap has not been previously reported.