A difficult airway in emergency craniotomy: A case report

Airway management in emergency neurosurgical patients presents significant challenges due to altered consciousness, elevated intracranial pressure, and the need for rapid yet cautious airway control to prevent secondary brain injury. Preoperative assessment is often limited, and unrecognized anatomical or hematological factors may complicate intubation. We describe a case of an unanticipated difficult airway in a 35-year-old female undergoing emergency craniotomy for traumatic epidural hematoma, where chronic kharrā (tobacco and areca nut) chewing, a common regional habit in central India, was the likely contributing factor. This case underscores how regional chewing habits can create hidden airway risks, particularly in patients with impaired consciousness, where conventional airway assessment is not feasible. It highlights the importance of prioritizing oxygenation, minimizing repeated instrumentation in thrombocytopenic patients, and maintaining readiness for surgical airway intervention. Furthermore, airway assessment methods that do not require patient cooperation, such as point-of-care airway ultrasonography (POCUS) and external anatomical indices, show promise for early identification of difficult airways in neurotrauma settings. Awareness of sociocultural factors, combined with structured, evidence-based airway management strategies, can improve preparedness and outcomes in emergency neurosurgical anesthesia.