Unusual difficult airway due to the presence of a large facial foreign body.

The anesthetic management of patients with facial trauma that directly or indirectly involves the airway can be challenging. We present this image that represents a 22-yrold female patient who suffered a penetrating stiletto shoe injury to the left eye incurred during an altercation. She arrived at the emergency department with the heel still embedded in the eye and the sole covering most of the facial structures and oronasal openings. A computed tomography scan indicated possible fractures of the left infraorbital canal/ orbital floor and the posterior wall of the left maxillary sinus along with the left maxillary hemosinus (Figure). Airway management was complicated by alcohol intoxication, recent food ingestion, agitation, and most importantly, significant elevation of intraocular pressure (33 mmHg). Emergent surgical removal was scheduled, and although cricothyrotomy and awake tracheostomy were considered, after the administration of an antisialagogue (glycopyrrolate 0.2 mg iv), dexmedetomidine (1 lg kg hr iv infusion), and 4% lidocaine airway toplicalization, an awake flexible fibreoptic intubation was performed through the very limited access to the patient’s mouth. Following induction of general anesthesia, the stiletto heel was extracted manually from the orbit, necessitating a significant amount of force. Afterward, the intraocular pressure decreased to 8 mmHg. No further surgery was required, tracheal extubation was performed at the end of the procedure, and the patient had an uncomplicated recovery. Although the use of awake video-assisted laryngoscopy for difficult airways has recently been described in the literature, this case re-emphasizes the role of flexible fibreoptic intubation as the ‘‘gold standard’’ in selected complex airway situations.