Airway Management in a Postmandibulectomy Patient with Osteoradionecrosis - A Case Report

Osteoradionecrosis (ORN) of the mandible is a severe iatrogenic disease of devitalised bone caused by radiation therapy of oropharyngeal cancers. ORN is characterised by exposed irradiated bone tissue that fails to heal within a defined period.[1] Surgical interventions of the jaw after radiation increase ORN risk due to impaired vascularisation.[2] Bag–mask ventilation is challenging in these patients due to fragile irradiated tissues, poor mask seal from ulcers or deformities, trismus and the risk of pathological jaw fractures. Conventional airway management techniques become challenging in irradiated patients, making awake tracheal intubation the gold standard approach.[3] However, anatomical complexity in these cases can lead to airway complications and catastrophes. We present the case of a 64-year-old male with a history of inability to close his mouth, dysphagia, loss of speech and episodes of dyspnoea. He was the known case of carcinoma left buccal mucosa with multiple recurrences. He had undergone marginal mandibulectomy with wide glossectomy and nasolabial flap reconstruction in 2011, followed by segmental mandibulectomy with free flap reconstruction in 2015 and 2023. Adjuvant radiation therapy (66 Grey in 30 fractions) was administered in 2012. His co-morbidities included hypertension, hypothyroidism, transverse myelitis and neurogenic bladder. On examination, the patient had fixed open mouth, absent upper and lower lips, immobile tongue adhered to the floor of mouth and a discharging sinus at the left cheek. The patient was in dyspnoea, orthopnoea and head turned to the left side for optimal comfort. The surgery planned was permanent tracheostomy and percutaneous endoscopic gastrostomy. After obtaining informed consent for awake fibreoptic intubation (AFI), the patient received intramuscular glycopyrrolate 0.2 mg. The Standard American Society of Anaesthesiologists monitoring was applied, and the patient was positioned at 30° head-up with the head turned left for the patient’s comfort. Oral AFI was chosen as tracheostomy under local anaesthesia was technically difficult and refused by the patient. The oral cavity was topicalised with 10% lignocaine spray and paraoxygenation via nasal route given at 10 L/min. Target-controlled infusion of remifentanil at 2 ng/mL provided sedation and analgesia. Following Difficult Airway Society guidelines,[4] the anaesthesiologist positioned in front of the patient and introduced the bronchoscope orally, utilising spray-as-you-go technique. The bronchoscope was navigated through the strictured pharyngeal opening, where visualisation of the vocal cords was obstructed by the epiglottis adherent to the posterior pharyngeal wall. The scope was manoeuvred through the parapharyngeal space, performing a U-turn manoeuvre in the pyriform fossa to visualise and enter the tracheal opening. A 6 mm flexometallic endotracheal tube was successfully railroaded over the bronchoscope. Tube position was confirmed via bronchoscopic visualisation and end-tidal capnography before inducing general anaesthesia. Postsurgery, the patient was reversed from anaesthesia and maintained on spontaneous ventilation via a T-piece connected to the tracheostomy tube. The perioperative period remained uneventful. ORN risk factors include tumour proximity to bone, radiation therapy and acute or chronic bone injury from multiple surgeries, dental extractions or infections.[2,5] This patient unfortunately experienced all contributing factors. All these insults created significant tissue distortion and anatomical abnormalities that rendered conventional airway assessment impossible. Preoperative computed tomography imaging revealed epiglottic adherence to the posterior pharyngeal wall [Figure 1] and also demonstrated extensive mandibular ORN. These findings guided the unconventional bronchoscope manoeuvre through the pyriform sinus. Success required bronchoscope flexibility, manoeuvrability and extensive hands-on experience with fibreoptic techniques. Given limited clinical opportunities, simulation-based training can enhance familiarity and proficiency for these demanding cases.Figure 1: Preoperative computed tomography showing epiglottic adherence to the posterior pharyngeal wall and mandibular osteoradionecrosisDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.