Airway Emergencies - expected difficult airway (2)

Pathological obstruction of periglottic area

Awake tracheostomy
Gas induction if you think the patient is intubatable
Do not use an awake FOB in periglottic tumour or epiglottitis, as the FOB will further narrow an already compromised airway in a patient struggling to breathe. Lignocaine spray to the cords or FOB irritating the larynx will induce an IRREVERSIBLE LARYNGOSPASM

Stridor may be present because of blood or debris, or the fracture itself.
An unstable bilateral fracture can push the tongue and paraglottic soft tissue into the upper airway.
A mobile maxilla can cause obstruction of the posterior pharynx.
Face-mask ventilation can move fractures posteriorly, causing obstruction.
Impaired mouth opening due to trismus or mechanical reasons
Avoid nasal intubation in Le Fort III fractures as tube can pass into skull
Nasal intubation in maxillary fractures can cause haemorrhage obstructing a view of the larynx. Should secure the airway with an oral ETT first.
NB Always consider associated head and cervical spine injury

Simple unilateral mandibular fracture with trismus, RSI is reasonable, otherwise consider gas induction or awake FOB.
Le Fort III fractures - awake tracheostomy is the safest option.
Retrograde intubation - does not require a direct view of the larynx.

Difficult to diagnose, requires a high degree of suspicion.
Dynamic situation which can worsen quickly
Safest approach is an AWAKE TRACHEOSTOMY, especially if complete disruption of the trachea is present