This chapter deals with difficult airway management in the context of otolaryngologic surgery. To a large extent, the airway management technique for otolaryngologic surgery will depend on clinical circumstances as well as the airway management skills of the anesthesiologist and the available equipment. Should intubation be difficult, clinicians can still provide ventilation and oxygenation via face-mask ventilation. Most patients undergoing otolaryngologic surgery have their airway managed via tracheal intubation. Difficult airway management for otolaryngologic surgery relies heavily on the American Society of Anesthesiologists difficult airway algorithm and, particularly, on the use of awake intubation in the spontaneously breathing patient. The use of fiberoptic intubation for the airway management of patients undergoing otolaryngologic surgery is popular because this technique works well in the presence of many kinds of airway pathology. Many clinicians opt to perform this technique under topical anesthesia with the patient only lightly sedated.

Airway anatomy and physiology are altered in obesity, and an understanding of these changes is key to appropriate airway management. Longitudinal studies of pulmonary function have shown reduction in pulmonary tests with obesity. The functional residual capacity (FRC) is reduced by the conduct of general anaesthesia. In the obese, the resting metabolic rate, oxygen consumption and also carbon dioxide production are all increased, compounding the reduction in FRC. In addition to acting as an oxygen store, FRC is important in splinting small airways. Respiratory mechanics are affected even in moderate obesity. Prediction of difficulty: Mallampati score and neck circumference are better predictors than body mass index (BMI) and a history of obstructive sleep apnoea (OSA), but their predictive value is not strong. Difficult mask ventilation and difficult intubation are uncommon. Awake intubation is worthwhile if difficulty is expected, because of the rapid desaturation problem.