Background:Extubation could also be as difficult as intubation. The higher risk for extubation failure is associated with obesity, goitre, obstructive sleep apnea, major head/neck and upper airway surgery,  and cervical spine surgery. The possible mechanical causes are laryngeal trauma, cuff herniation, damaged pilot tube, adhesion to tracheal wall and surgical fixation of the ETT.There are no algorythms for difficult extubation due to mechanical causes.Case Report:We report the case of a 57-year-old woman, ASA status III, who underwent the tumor surgery of left parotid gland. Induction and maintance of general anesthesia were uneventful. Extubation was planned 20 hours after she was placed in ICU. The cuff was deflated, but it was not possible to pull the ETT out due to high resistance. Nasogastric tube was taken out for suspected knicking with  ETT, antiedematous therapy was administered, and oxygenation and hemodynamic stability were mainteined. Fiberoptic bronchoscopy was done both through the nose and ETT in search for oedema, obstacles and signs of accidental surgical fixation, that also surgeon excluded. ETT was passable, without signs of cuff herniation. After that, videolaryngoscopy in analgosedation was done, with bougie placed in the ETT to secure the route and enable urgent intubation if the sudden laryngospasm occurs. Videolaryngoscopy  showed signs of the arythenoids oedema, that could be a result of attempts of extracting ETT. Signs of hemorrhage, lateral shift of anatomical structures or surgical fixation of ETT were not present, so ETT was forcefully pulled out with rotation and traction. Eventually, cuff invagination was observed.There were no respiratory sequellae after ETT being removed, and the patient recovered well. Discussion:Besides anatomical changes, mechanical causes of the tube malfunction may rarely cause difficult extubation, that is seldom present in literature in the form of case reports.Possible mechanical malfunction or cuff invagination in combination of arythenoid oedema may be the explanation for difficult extubation of our patient.After extubation airway collapse may occur and it is important to secure the airway so algorithm is needed  in order not to jeopardize the patient.Learning points:Whenever difficult extubation is present it is important to check the tube patency, to search for existing oedema of the epiglotis or the vocal cords, and the signs of surgical fixation. Difficult extubation algorithm is required.

07 / Forcefull difficult extubation due to cuff invagination in patient after parotide tumor surgery: the need for algorithm