A 52-year-old man with known acromegaly (enlarged tongue, prognathism, Mallampati class III) is scheduled for elective transsphenoidal pituitary surgery. The anaesthetist anticipates a difficult airway. Which is the SAFEST method of securing the airway in this patient?
- A Inhalational induction with sevoureane preserving spontaneous ventilation
- B Rapid sequence induction with direct laryngoscopy and succinylcholine
- C Awake fibreoptic bronchoscopy-guided nasotracheal intubation ✓
- D Intravenous induction with propofol followed by video laryngoscopy
Explanation
Acromegaly causes macroglossia, prognathism, hypertrophied pharyngeal and laryngeal soft tissues, and a narrowed glottic inlet, making both mask ventilation and intubation potentially difficult. When a difficult airway is anticipated, the safest approach is to secure the airway while the patient is awake and breathing spontaneously using fibreoptic bronchoscopy. Rapid sequence induction (option B) or standard IV induction (option D) risks cannot-intubate, cannot-ventilate scenarios. Inhalational induction (option A) is less reliable in adults and does not guarantee airway control. ASA difficult airway guidelines recommend awake fibreoptic intubation for anticipated difficult airways.
Reference: Miller's Anaesthesia, 9th ed.
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Written and medically reviewed by the StethoPrep medical team.