In impending airway obstruction attributable to cancer progression, it is often difficult to decide whether awake fiberoptic intubation or awake tracheostomy constitutes the best option. Prolonged attempts during either technique may precipitate catastrophic loss of airway. There is no guideline for the selection of awake tracheostomy versus awake fiberoptic intubation when a truly difficult airway is encountered.

Awake fiberoptic intubation focuses on the periglottic area.1  Nasopharyngoscopy of a patient with supraglottic cancer showed tissue edema, copious secretions, and obstruction of the glottis (panel A). Difficulties were expected for both airway topicalization and access to the glottic opening. Even if the glottis could be visualized, repeated intubation attempts may cause bleeding and fragmentation of friable tumor. Consequently, awake tracheostomy was chosen to secure the airway.

Awake tracheostomy focuses on the tracheal area.2  A second patient with a pretracheal tumor presented with intermittent stridor. His neck showed dense radiation fibrosis and tight surgical scarring (panel B). He was unable to lie supine and extend his neck to bring the trachea upwards. Image study (panel C) is critically important for both surgeon and anesthesiologist to understand the patient’s unique anatomy and assess the difficulty of tracheostomy, either awake or under anesthesia. Tracheostomy tube insertion may be difficult because of tracheal deviation, stricture, or tracheomalacia. Therefore, awake fiberoptic intubation was performed before tracheostomy.

Intubation and tracheostomy involve different paths presenting different obstacles. Close anesthesiologist/surgeon collaboration is crucial in these challenging awake techniques. Finally, because rescue cricothyroidotomy3  may be difficult, extracorporeal oxygenation should be considered as a backup plan.

The authors declare no competing interests.

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