Background: The usefulness of epidural catheter to anaesthetize the airway in preparation to awake fibreoptic tracheal intubation is well established [1]. We present a case of retropharyngeal abscess in which the epidural catheter proved to be an effective and secure approach to anesthetize the larynx and trachea.
Case Report: A 71-yeard old male with history of hypertension and hypercholesterolemia was proposed for emergency surgical drainage of retropharyngeal abscess. In the emergency department, he presented himself with altered mental status and mild hypoxemia (oxygen saturation 89%) despite face mask oxygen therapy (15 L/min). Since this was an anticipated difficult airway with partial obstruction, we decided for an awake fibreoptic intubation. The nose and pharynx were anesthetized with topical lidocaine. The fiberscope was introduced through the nostril and progressed until the oropharynx, where a bulking mass displaced the epiglottis posteriorly. A narrow column of air was identified and the epidural catheter, placed in the working channel of the fiberscope, advanced through it. Additional 40mg of lidocaine 2% were injected in the epidural catheter to atomize the local anaesthetic in the larynx and trachea. Then, the fiberscope progressed until the trachea and the patient was intubated with a nasotracheal tube (6.0”) without complications. 
Discussion: Among the various techniques described to anesthetize the larynx, local anaesthetic spray through epidural catheter provides several advantages: availability, non-invasive, reliably and safely reaching areas beyond airway obstruction. Local anaesthetic nebulization or spray through the fiberscope would probably be ineffective due to the airway obstruction. In case of infection, invasive procedures, such as nerve blocks or trans-tracheal injection, pose the risk of significant complications: in the event of abscess perforation, leakage of pus to the airway may have catastrophic consequences.
References: [1] Anesthesiology 11 2004, Vol.101, 1253
Learning points: This case reflects on anaesthesia of the airway for awake fibreoptic tracheal intubation, a much discussed issue, in a quite challenging situation. In a difficult airway management due to a retropharyngeal abscess, the epidural catheter proved to be a successful and safe method to anesthetize the larynx and trachea beyond the obstruction.

Is epidural catheter the best choice to anesthetize a partially obstructed airway for an awake fiberoptic tracheal intubation?