• Luan Oliveira Ferreira, Victoria Winkler Vasconcelos, Imaikon Gomes de Lima, Juliana Barbosa de Souza, and Karina Dias Resende.
• Programa de Residência Médica em Anestesiologia, Hospital Universitário João de Barros Barreto, Belém, Brasil.
• Medicine (Baltimore). 2023 Jun 9; 102 (23): e34028e34028.

RationaleNasotracheal intubation is an advanced airway modality used in specific contexts, such as limited mouth opening, macroglossia, cervical spine instability. In addition, it can be performed with the patient awake, especially when predictors a difficult airway are unknown.Patient ConcernsA 41-year-old male with a lesion in the C1 cervical vertebra, associated with a fracture of the right maxilla, was intubated through the nasopharyngeal route while awake. The forms of induction were discussed.DiagnosesBased on the mechanism of trauma and on the report of pain, associated with imaging examination, fracture of the body of the right maxilla and a complex fracture of the anterior arch of the C1 cervical vertebra were diagnosed.InterventionsIn this case, we present a patient with trauma to the face and spine who was intubated through the nasopharyngeal route while awake and guided by video laryngoscopy and using a rigid cervical collar. The patient was operated on under total general anesthesia (propofol and remifentanil) and plates and screws were placed for maxillary osteosynthesis. The pain was alleviated with a peripheral block of the trigeminal nerve of the maxillary branch with 0.5% levobupivacaine.OutcomesThe patient woke up from surgery, was extubated uneventfully and without pain. Cervical spine injuries were followed up by the neurosurgery team for conservative treatment.LessonsPatients with neck injury and facial trauma may need a definitive airway either for emergencies or for elective procedures. Intubating the awake patient may be an option when the anatomy of the cavity is unknown, and inducing the anesthetic act without this knowledge may be a inappropriate option, due to the risk of intubation/ventilation difficulties.Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.

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