The Cunning Airway: Anesthetic Insights From a Five-Case Series on Intubation Challenges Without Tracheostomy in Catastrophic Maxillofacial Injury

Panfacial trauma involves concurrent injuries to the upper (frontal), mid-face (maxilla, zygoma, nose), and lower (mandible) thirds of the face. This creates a significant threat to airway patency due to anatomical distortion, bleeding, edema, and the risk of aspiration. Airway management in panfacial trauma is complex and requires a strategic, individualized approach. Any error in this process may lead to considerable morbidity and mortality in both prehospital and hospital settings and can also complicate subsequent fracture reconstruction. Rapid and appropriate airway control is crucial to prevent hypoxia, facilitate surgical repair, and support postoperative recovery. This case series includes patients with panfacial fractures who required surgical management and advanced airway techniques. Approaches used include awake fiberoptic nasotracheal intubation, awake fiberoptic orotracheal intubation, awake video-laryngoscope-guided orotracheal intubation, and submental intubation. Submental intubation was performed in Cases 1-4, and nasal intubation was used in Case 5 to provide optimal access for both anesthetists and surgeons. Each case is reviewed for clinical presentation, airway technique, intraoperative findings, and postoperative outcomes. The approach used helped achieve better patient outcomes, supported early recovery, and avoided the need for surgical airway access such as tracheostomy or cricothyroidotomy. The planning and management process highlights the importance of timely decision-making, the availability of advanced airway equipment, and the goal of avoiding a surgical airway whenever possible.