Resurgence of Blind nasal intubation with Videolaryngoscopy as a guide for head maneuvers in the course of nasotracheal intubation in panfacial fracture patients with severely restricted mouth opening.

Background: Majority of the patients with pan facial fractures have severe limitation of mouth opening, particularly involving the zygoma and the angle of mandible. Airway management is challenging in these cases, especially if mouth opening is less than 20 mm(1). Awake nasal fiberoptic intubation is the standard technique of airway management in these patients posted for reduction of faciomaxillary and mandibular fractures. However, in case of failed fiberoptic due to bleeding, particularly in panfacial trauma, the only option of securing the airway left is the surgical one. Blind nasal intubation can act as a bridge between a failed fiberscope attempt and a surgical airway, but it has become a dying art in present scenario(2). 
Case report: In this report, we describe a series of five cases of panfacial fractures with severe restriction of mouth opening where fiberoptic intubation was not possible due to bleeding or logistical issues. Moreover, a videolaryngoscope blade could be just introduced into the oral cavity but manipulation with a Magill forceps was not possible. In all these cases, we successfully secured the airway with a Macintosh-shaped C-Mac videolaryngoscope showing the laryngeal view and the head maneuvers done similar to the blind nasal intubation technique to guide the endotracheal tube past the vocal cords. 
Discussion: In all the cases, it was possible to introduce the slim Macintosh type of C-Mac blade (maximum height 14 mm), but any maneuvering with Magill forceps was not possible, therefore head maneuvering similar to the blind nasal technique was complemented with the videolaryngoscope and the airway secured with much more ease than the blind nasal intubation due to objective means of guiding the maneuvers. This technique can serve as bridge between failed intubation and a surgical airway. Moreover, it could replace the standard nasal fiberoptic technique as plan A of airway management with patients of panfacial trauma with high risk of bleeding.
References:
1.	Hagberg CA. Benumof and Hagberg's airway management. 3rd ed. Philadelphia, Elsevier Inc. 2013, pp 403-41.
2.	Zhang J, Lamb A, Hung O, Hung C, Hung D. Blind nasal intubation: teaching a dying art. Can J Anaesth 2014; 61: 1055-6.
Learning points:
•	Videolaryngoscopy can be used as an important tool for head maneuvering during blind nasal intubation in severely restricted mouth opening in panfacial fracture patients.

Resurgence of blind nasal intubation with videolaryngoscopy as a guide for head maneuvers in the course of nasotracheal intubation in panfacial fracture patients with severely restricted mouth opening