Journal of Clinical Anesthesia (2016) 34, 314317

Case Report

Transorbital endotracheal intubation:

a nonstandard approach to a difcult airway,,
Nathan H. Waldron MD (Resident)a,, Bryant W. Stolp MD, PhD (Assistant Professor)a ,
Michael P. Ogilvie MD (Fellow, Plastic Surgery)b ,
David B. Powers MD, DMD, FACS, FRCS (Ed) (Associate Professor of Surgery; Director,
Duke Craniomaxillofacial Trauma Program)b ,
Michael R. Shaughnessy MD (Assistant Professor)a
a

Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA

Department of Surgery, Duke University Medical Center, Durham, NC, USA

Received 2 February 2016; revised 8 April 2016; accepted 2 May 2016

Keywords:
Airway management issues;
ENT surgery;
Fiberoptic intubation;
Oral surgery;
Critical care issues;
Education in anesthesia

Abstract We present the case report of a 49-year-old gentleman with a history of adenoid cystic carcinoma
of the left nare status post curative bifrontal craniotomy, left lateral rhinotomy and medial maxillectomy,
adjuvant radiotherapy, and orbital exenteration for optic neuropathy, complicated by medial wall
dehiscence. His course was also complicated by severe radiation trismus, for which he was scheduled to
undergo bilateral mandibular coronoidectomies. Given his limited mouth opening, the surgeon requested
a nasal endotracheal tube. Because of concerns of traumatizing his nare, we utilized a exible beroptic
bronchoscope to perform asleep transorbital intubation. Airway management in patients with severe trismus
may require ingenuity.
2016 Elsevier Inc. All rights reserved.

1. Introduction
Trismus is a known adverse sequelae of radiation therapy
for head and neck malignancies that signicantly reduces quality of life [1]. Arising from radiation-induced brosis of the

Conicts: All authors reported no conicts of interest.

Attestation: All authors approved the nal manuscript.

Funding: This study was funded with departmental funds. N.H.W. is supported by a Foundation for Anesthesia Education and Research fellowship grant.
Corresponding author at: Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710, USA. Tel.: +1 919 724 5217; fax: +1
919 681 7893.
E-mail addresses: nathan.waldron@dm.duke.edu,
nathan.h.waldron@gmail.com (N.H. Waldron), bret.stolp@dm.duke.edu
(B.W. Stolp), michael.ogilvie@dm.duke.edu (M. Ogilvie),
david.powers@dm.duke.edu (D.B. Powers),
michael.r.shaughnessy@dm.duke.edu (M.R. Shaughnessy).

http://dx.doi.org/10.1016/j.jclinane.2016.05.005
0952-8180/ 2016 Elsevier Inc. All rights reserved.

muscles of mastication, trismus may be treated with exercise

therapy utilizing jaw-mobilizing devices to increase mouth
opening [2]. Unfortunately, radiation trismus may be refractory to exercise therapy [3] and require surgical procedures
(mandibular coronoidectomies) to increase mouth opening
[4]. Patients with severe trismus present a challenge for airway
management. We present a novel airway management strategy
for a gentleman with severe trismus related to radiation brosis
presenting for bilateral coronoidectomies.
The patient detailed below has given written permission for a
case report detailing his anesthetic management to be published.

1.1. Case description

We describe a 49-year-old patient with a history of T3 N0
cystic adenoid carcinoma of the left nare, diagnosed in 2008.

Transorbital endotracheal intubation

He underwent a bifrontal craniotomy, left lateral rhinotomy,
and medial maxillectomy in 2008. He also underwent adjuvant
radiation therapy of 60 Gy treated from November to December 2008. In 2010, he experienced 2 recurrences, both treated
with wide local excision. In addition, he had malignant perineural invasion of the trigeminal distribution of V2 in 2012,
which was treated with proton beam therapy.
Unfortunately, he experienced deteriorating vision in his
left eye as a result of radiation and underwent a left orbital exenteration in 2013. This procedure was complicated by a medial wall dehiscence, leaving him with a persistent 8- to 9mm communication between his orbit and oropharynx, for
which he wore an oral prosthesis. Also as a result of his radiation, he experienced severe trismus with an oral opening of
5 mm, which precluded rigorous dental hygiene and had resulted in dental caries. He presented to the operating room
for bilateral mandibular coronoidectomies. Because of inadequate available space at the operative site, the attending surgeon requested a nasal intubation.
The patient had obvious radiation brosis of the left nare,
and also reported symptoms of nasal obstruction in the contralateral (right) nare, raising suspicion for radiation damage. Occlusion of the left (radiated) nare and forceful inspiration
produced minimal airow through the right (nonradiated) nare, but brisk air movement through the left facial defect. Of
note, the patient was quite tall (203 cm), potentially requiring
a long nasal RAE tube for intubation. After discussion with the
patient, we agreed upon attempting transorbital intubation to
avoid traumatizing his patent nostril. Of note, the patient had
been easy to mask ventilate (after occluding the facial defect)
during a recent anesthetic at our institution. Additional medical
history was notable for peripheral neuropathy due to chemotherapy and chronic oral pain on tapentadol 250 mg twice daily.
The patient was premedicated with 2 mg of midazolam prior to arrival in the operating room. With patient permission,
we placed an 100-mL bag of normal saline over the facial defect and commenced standard preoxygenation. Capnography
and measurement of end-tidal oxygen both showed satisfactory air movement with this method. Anesthesia was induced
with lidocaine, fentanyl, and propofol. Mask ventilation was
easy with the 100-mL bag of normal saline covering the facial
defect. After administration of neuromuscular blockade, a
exible beroptic scope (exible intubation video endoscope,
4.0 mm 65 cm, manufactured by Karl Storz Endoscopy)
was advanced into the orbital cavity. After navigating through
a pathway of inamed tissue, past inferior turbinates, into the
oropharynx, and then through the glottis, a 6.0 microlaryngeal
tube (Mallinckrodt Hi-Lo Oral/Nasal cuffed tracheal tube, 8.2mm outer diameter, 28.5-cm length; Covidien) was gently advanced atraumatically past the cords (Figs. 1 and 2). Careful
inspection of the entire stula tract after ETT placement revealed no evidence of bleeding from the friable tissues. The
case proceeded uneventfully, with successful coronoidectomies improving oral opening from 5 to 40 mm. The patient
was extubated at the end of surgery and discharged home on
postoperative day 1.

315

2. Discussion
In this report, we detail a novel airway management technique for a patient with severe radiation trismus undergoing bilateral coronoidectomies. Trismus, dened as a mouth opening
b 35 mm, is estimated to affect between 5% and 38% of head
and neck cancer patients, although estimates vary signicantly
[5]. Exercise therapy may benecial to increase mouth opening, and thereby functionality, in radiation trismus [6]. Unfortunately, conservative therapy may fail, necessitating surgical
intervention. In a prospective case series of 18 patients with radiation trismus who had failed conservative therapy, all patients had an increase in mouth opening 20 mm after
coronoidectomy. In addition, all patients maintained an interincisal distance 35 mm for at least 6 months [7], indicating
that coronoidectomy generally gives durable benet to patients with refractory radiation trismus.
Patients with radiation trismus present a signicant airway
management challenge for anesthesiologists. Although there is
no formal minimum mouth opening required for laryngoscopy, 20 mm has been proposed as a reasonable threshold [8].
In patients with extremely limited mouth opening requiring
endotracheal intubation, nasal intubation may be a suitable alternative. However, patients receiving radiotherapy for nasopharyngeal carcinoma have a 32% incidence of sinonasal
complications (including choanal stenosis, chronic sinusitis,
osteoradionecrosis, and/or nasal synechiae), potentially complicating nasal intubation [9]. When nasal intubation is unsuitable and tracheostomy undesirable, retromolar intubation is a
potential option for securing the airway [10]. Unfortunately,
intraoral surgery precluded retromolar intubation in our patient. As such, we chose to explore alternative options for endotracheal intubation prior to risking nasal/sinus trauma or
entertaining tracheostomy.
Our patient's unique anatomy made transorbital intubation
feasible. Orbital-nasal and orbital-sinus connections are a
known complication of orbital exenteration [11]. Oro-antral
stulas, or unnatural communications between the maxillary
sinus and the oral cavity, can arise from a diverse set of circumstances, including trauma, tumors, maxillary pathology,
or most commonly from extraction of the rst and second
maxillary molars [12]. Together, our patient had a patent tract
traversing the medial orbital wall, maxillary sinus, and oropharynx prior to arriving in the hypoglottic region. There are
limited prior reports of transorbital intubation in the literature
[1317]. In 2 prior reports, a laryngoscope was used either
through the orbital defect [13] or orally [17] to visualize the
glottis. An alternative strategy for patients with small orbital
defects is to use a beroptic bronchoscope, as we did in our
case. In the 2 previous reports of beroptic transorbital intubation [14,15], the orbit was topicalized, the patients were sedated, and spontaneous breathing was maintained throughout
intubation. In our case, we chose to induce general anesthesia
prior to any airway manipulation because we had the benet of
a recent anesthetic record with clear documentation that our
patient was easy to mask ventilate. Our comprehensive

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N.H. Waldron et al.

Our report adds to the current body of literature detailing
novel airway management strategies for patients with severe
trismus. Key components of our plan were ensuring adequate
mask ventilation after occluding the orbit and the use of a
microlaryngeal endotracheal tube in order to minimize orbital/sinus trauma. Our solution allowed us to minimize risk of
epistaxis and damage to the patient's contralateral nare, while
also avoiding potential complications of tracheostomy. In addition, a thorough preoperative examination and conversation
with our patient regarding the relative merits of transorbital vs
nasal intubation vs tracheostomy was important. Although
transorbital intubation may seem morbid, our strategy allowed
us to spare our patient potential complications of nasal intubation [18]. Anesthesiologists caring for patients with complex
head and neck anatomy are encouraged to consider novel techniques for securing the airway when it might provide patient
benet or minimize potential harm.

References
Fig. 1 Side prole of transorbital endotracheal tube placement. Image also serves to display patient's maximal preoperative mouth
opening (interincisal distance of 5 mm).

preoperative discussion with the patient covered risks of transorbital intubation, including bleeding, as well as potential backup
plans, including inability to perform intubation and resultant
emergence from anesthesia, or emergency tracheostomy.

Fig. 2 Head-on view of transorbital endotracheal tube placement.

Also note obvious radiation brosis of the left nare, with radiation
changes on the right aspect of the nose, as well.

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