This chapter deals with difficult airway management in the context of otolaryngologic surgery. To a large extent, the airway management technique for otolaryngologic surgery will depend on clinical circumstances as well as the airway management skills of the anesthesiologist and the available equipment. Should intubation be difficult, clinicians can still provide ventilation and oxygenation via face-mask ventilation. Most patients undergoing otolaryngologic surgery have their airway managed via tracheal intubation. Difficult airway management for otolaryngologic surgery relies heavily on the American Society of Anesthesiologists difficult airway algorithm and, particularly, on the use of awake intubation in the spontaneously breathing patient. The use of fiberoptic intubation for the airway management of patients undergoing otolaryngologic surgery is popular because this technique works well in the presence of many kinds of airway pathology. Many clinicians opt to perform this technique under topical anesthesia with the patient only lightly sedated.

Cervical spine mobility is central to the conventional safe management of the airway. Acquired causes are mainly degenerative diseases (osteoarthritis, degenerative disc disease), inflammatory processes (rheumatoid arthritis, ankylosing spondylitis), trauma, and prior surgical fusion. This chapter presents a case study of a 68-year-old male with severe ankylosing spondylitis who sustained a fracture through the C6 vertebral body following a fall. The patient was positioned in the prone position with care taken to avoid cervical spine extension and to preserve the alignment of the cervico-thoracic spine, to the extent that was possible given the underlying deformity. The blood pressure was maintained at preinduction values at all times. The patient presented in this case demonstrated several of the features that predict difficulty in airway management. Awake flexible fiberoptic intubation is considered to be the gold standard in this challenging patient group.