To the Editor:—
Sander et al. 1describe fiberoptic transorbital intubation, a valuable alternative to tracheotomy in an unusual group of patients. We would like to mention that additional options exist that may be suitable for many patients in this group. On several occasions, we have intubated similar patients through the orbit and have found success using awake, direct laryngoscopy with topical anesthesia. A long, straight laryngoscope blade, such as a Miller 3 or longer blade, can be used in conjunction with an endotracheal tube with a predominantly straight stylet. Anatomic requirements for the use of direct transorbital laryngoscopy include the previous removal of the orbital floor and maxillary bones in such a way to create a straight pathway for visualization of the vocal cords. To perform direct laryngoscopy, the laryngoscope blade is first passed through the empty orbit. The laryngoscope blade is then used to sequentially elevate the soft palate, tongue, and finally the epiglottis to allow direct visualization of the vocal cords. Although the fiberoptic technique may be successful in most situations, direct laryngoscopy as mentioned here may be advantageous when fiberoptic laryngoscopy is rendered difficult by blood or secretions or when a fiberoptic scope cannot be immediately obtained. A lighted stylet may also be useful as an alternative to fiberoptic transorbital intubation when situations render fiberoptic visualization difficult.