Ambuscope-Assisted Intubation and Opioid-Free Anesthesia with Open Cervical Plexus Block in Oral Cancer Surgery with PMMC Flap and Oral Submucous Fibrosis: A Rare Anesthetic Challenge

Abstract Background: Oral submucous fibrosis (OSMF) is a precancerous condition associated with trismus and a high risk of oral squamous cell carcinoma (SCC). Anesthetic management is challenging due to airway restriction and prolonged surgery requiring flap reconstruction. Opioid-free anesthesia, though increasingly explored, remains rarely reported in this complex context. Case: We report the perioperative management of a 31-year-old male with OSMF and infiltrating SCC of the oral cavity, posted for wide local excision, modified radical neck dissection (MRND), and pectoralis major myocutaneous (PMMC) flap reconstruction. Anticipating difficult airway, nebulisation and airway block were given, followed by Ambuscope-assisted nasotracheal intubation with a 7.5 mm flexometallic tube. An opioid-free anesthetic plan was executed using dexmedetomidine infusion, sevoflurane, and non-opioid adjuncts. At the end of surgery, an open superficial cervical plexus block was administered under direct surgical vision for postoperative analgesia. Surgery lasted 6 hours with stable intraoperative hemodynamics. Postoperatively, the patient was electively ventilated in ICU for 2 hours, extubated uneventfully, and remained comfortable with paracetamol and diclofenac as rescue analgesia. No opioids were used intraoperatively or postoperatively.Conclusion: This case demonstrates the feasibility of a multimodal opioid-free anesthetic strategy in major oral cancer surgery with flap reconstruction and difficult airway. The novel use of an open cervical plexus blocks further enhanced postoperative analgesia, making this an educational and rarely reported anesthetic scenario.