Awake Fiberoptic Intubation for Segmental Mandibulectomy in a Patient with Follicular Ameloblastoma of the Anterior Mandible: A Case Report.

Abstract

Awake tracheal intubation (ATI) is recommended for patients with predicted difficult airways. This approach preserves spontaneous ventilation until the airway is secured. In this case, a 52-year-old male (ASA II) with a large anterior mandibular tumor underwent segmental mandibulectomy. Awake fiberoptic intubation (AFOI) was performed nasally via a flexible bronchoscope in a semi-sitting, face-to-face position. Topical anesthesia was achieved by combining nebulized 2% lidocaine (4 mL, 80 mg) with the spray-as-you-go technique (2-4 mL of 2% lidocaine). The total dose used was approximately 120-160 mg, or 1.8-2.5 mg/kg for a 65-kg patient. Sedation was achieved with dexmedetomidine (loading dose 1 µg/kg over 10 minutes, then maintenance at 0.4 µg/kg/hour). As HFNO was unavailable due to limited equipment availability, oxygenation was maintained using a low-flow nasal cannula at 3 L/min. Tracheal tube placement was confirmed by direct visualization and capnography. No episodes of desaturation occurred. This report highlights the practical adaptability of the DAS sTOP framework for AFOI when HFNO availability is limited, demonstrating that low-flow nasal oxygen combined with dual-method topicalization and a single sedative agent may serve as a feasible alternative.