Fiberoptic Nasal Intubation

On call in pediatrics today, we had an emergency case of a patient with a critical airway. A four year old had an extremely swollen tongue, so bad he couldn't eat, drink, or even breathe through his mouth. His voice was severely distorted. Looking into his mouth, all I could see was tongue. How do we secure the airway for the ENT surgeons to excise the lesion?

Luckily, the four year old had an IV and in fact was incredibly cooperative through the entire procedure. We used dexmedetomidine and ketamine for the child to fall asleep, a carefully selected combination of anesthetics to keep the patient spontaneously ventilating. Then after a lot of oxymetazoline, I inserted a tiny pediatric fiberoptic endoscope into the nose, following it back into the pharynx. I navigated around the massively enlarged tongue until I could see the vocal cords. I had to time my movements to the patient's breathing; as inhalation opened the airway, I had to quickly duck through the cords into the reassuring tracheal rings. We then slid the endotracheal tube over the scope and ventilated the lungs. It was a lot of fun, a little nerve-wracking, and pretty satisfying in the end.

Image shown under Fair Use, from faculty.washington.edu.