• XianHe Zheng, ChangFeng Zhang, ShuMei Lian, ShuYun Liu, and ZongMing Jiang.
• Department of Anesthesia, Shaoxing University Affiliated First Hospital.
• Medicine (Baltimore). 2020 Aug 7; 99 (32): e21521.

RationaleThe establishment of lung isolation is often particularly challenging for the anesthesiologist in patients with difficult airway. Usually, orotracheal intubation with double lumen tube is the commonly used technique for achieving 1 lung anesthesia. Whereas, in patients with limited mouth opening and restricted cervical mobility, this technique becomes extremely difficult and hazardous. We report a case in which bronchial blocker placement was succeeded via both nostrils in a difficult airway due to restricted mouth opening.Patient ConcernsA 50-year-old, non-smoking female with a painless mass in the left upper lobe. She had a 10-year history of ankylosing spondylitis and squamous cell carcinoma of the floor of the mouth after 5 operations 4 years previously.DiagnosesLeft upper lobe adenocarcinoma, ankylosing spondylitis and oral squamous cell carcinoma.InterventionsTo achieve 1 lung anesthesia, both nostrils were used for extraluminal bronchial blocker placement.OutcomesInitially, oral intubation was selected for establishing a patent airway but failed. Then switched to nasal canal for insertion, after several attempts, a conventional nasal intubation tube (internal diameter 6.0 mm) was placed via 1 nostril under topical anesthesia, with the aid of a flexible fiberoptic bronchoscope, and a bronchial blocker was advanced to the desired position via the other nostril.LessonsIn difficult airway with limited mouth opening and restricted cervical mobility, multidisciplinary experts participated discussion is a prerequisite for contemplating a scientific plan. Preoperative computed tomography scan and 3-dimensional computed tomography reconstruction would be helpful in detecting the narrowest part of airway conduit and determining a safe, reliable, and feasible airway program.

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