I would choose a fibreoptic laryngoscope as a means for tracheal intubation.

Tracheal intubation guided by fibrobronchscopy is the method of choice in similar cases (via nose). If an experienced bronchoscopist is not available in emergency case, then tracheotomy should be considered.

we have similar case and have good experience with fibroopic, i mean reoperation for oral cavity cancer with pervious radiation

I will do Awake Fibreoptic Nasal intubation. There are various options to use LA for nostril, oropharynx and trachea. We use LA nasal spray and 10% lignocaine spray with automiser device and spray as you go via a epidural catheter threaded through scope and use 4% lignocaine.

in my idea ,awake nasal intubation as dr salmin explained is a very safe procedure

 Dear fellows, the FOB is choice for difficult intubation, but in this case with coagulopathy, do you accept the risk of bleeding?

Although nasal FOB is the obvious answer, the key here is preparation of the nasal cavity because of the coagulopathy. I would also do this under anaesthesia, because if things go bad,you can proceed very quickly to cricothyroidotomy/tracheostomy. So, before induction, check which nostril appears the most patent. Once unconscious, use a vasoconstrictor in the nasal cavity.  Although cocaine paste is very effective, it can cause problems if (and it will) gets onto the FOB lens. The alternative is pledgets soaked in 1:1000 adrenaline. I'm sure people have other good suggestions. Don't be in a rush. Use a relatively small diameter tube to minimise trauma, both on insertion and at extubation. Remember, bleeding will probably be significant at extubation, so extubate awake, and again have some adrenaline soaked pledgets available. You also need a surgeon scrubbed ready to proceed and one who isn't going to complain about the bleeding if and when he starts!

An awake intubation via the nasal cavity.  Do not risk putting the patient asleep without securing the airway.  Bleeding is a risk but a lost airway is paramount.  Maybe a fiberoptic would work but a blind nasotracheal approach should be considered.  Inject 3cc of 1% xylocaine into the trachea, perhaps add a xylocaine spray to the back of the throat, then KY jelly in the right nostril, then do a slow insertion of a small bore nasotracheal tube down the right nostril into the trachea.  If the blind intubation fails, have the surgeon do the tracheostomy under local anesthesia with the patient awake.

All of you concentrated on intubation, but I think it is not the priority. I would start with treating coagulopathy first, as it may be a problem during surgery, too. Secondary -  procced to anaesthesia and surgery. What about starving or risk of aspiration during induction? What about type of surgery? There is not enough information concerning this patient. Openng mouth less than 1 cm is really a rare situation, I mean this is simlpy just a brain storming story but with limited data to get some solution. 

Jiri is of course correct. In the UK we have prothrombin complex concentrate and I would use this preop. However, don't expect absolutely normal clotting clinically. It's good, but not a panacea. Mouth opening less than 1 cm depends on the population you deal with. I've seen this  in patients with no other confounding issues; I've inserted a 16g cannula under LA through the cricothyroid membrane to allow oxygenation using a high-pressure source (eg Manujet Sanders injector). Induce anaesthesia, maintain with TIVA and  neuromuscular blocking drug and perform nasal FOB intubation. Interestingly, worst case took 40 minutes (previous radiotherapy), but immediately after intubation ABGs were normal. There are no doubt lots of ways, I think the most important thing is not to be using a completely untried technique for the first time in such a case.

Obviously if you are not faced with an emergent situation, you can hopefully reverse the coagulopathy before undertaking airway management. If you are not afforded that luxury, than the answers given above should help. If you have no time for reversal, and you cannot succeed with blind or visualized nasotracheal intubation, then you have to proceed to cricothyrotomy. You will need to be prepared for multiple units of blood transfusion while you try to reverse the coagulopathy.

I agree with Dr. Rosen. The question tackles an emergent situation which does not  afford time for treating the coagulopathy (whatsoever it is !).  

It depends on how emergent the airway is.

My preference would be for a fibre-optic assisted nasotracheal intubation with reversal of coagulopathy if at all possible.

If this was a "crash airway", then surgical cricothyroidotomy would the first procedure to be considered.

I would like to share my thoughts. In general, there is no optimal solution for this case:

1. In a full stomach patient, the topicalization would not be ideal. Then an ultrasound study of the stomach would help visualizing of the stomach contents. A semi-sitting position, premedication with a prokinetic agent such as metoclopramide 20 mg iv, and suctioning the stomach while awake through NGT could be tried.

2. The anticoagulant medication hasn't been mentioned. The prothrombin complex works only for Vit-K dependent agents i.e. warfarin. The newer agents don't have virtually an antidote.

3. With a 1-cm mouth opening it would still be possible to try an oral FOB using a 5 mm scope with a 6 - 7 mm ID ETT. The OD of the ETT should be watched and tested for passage through the 1-cm slit beforehand. Topicalization could be achieved just by gargling lidocaine 2% solution if possible. Spraying through the suction port of the FOB is another option provided that the small diameter FOB is equipped with a suction port.

4. A nasal decongestant spray e.g. Otrivin would be useful before nasal attempts, plus generous lubrication of the ETT as well as warming the ETT in hot water for a few minutes.

5. In case of a failed awake FOB, or a "crash airway", then the surgical cricothyroidotomy would obviously follow; however, what would the definitive airway management plan be? A retrograde intubation through the cricothyroidotomy could be tried though it may have its own challenges especially finding the tip of the guidewire in the oropharynx as well as passing the ETT tip through the VCs by a twisting maneuver.

We all know there are multiple ways of securing a difficult airway. However for the scenario presented here the additional concern is a uncorrected coagulopathy. All those who might regularly do a fiberoptic nasal intubation might be well aware of the fact that despite adequate precautions and preparation railroading the ETT over successfully inserted fiberoptic bronchoscope might cause significant nasal bleed. To me its a bad choice to think of any nasal intubation tecnique in a uncorrected coagulopathy. Yes ! oral fiberoptic guided intubation does makes sense. We must perhaps choose a technique that will result in minimum chance of bleeding. To me if the anaesthesiologist is skilled and experienced in this technique he must think of Retrograde intubation using a J tipped guide wire and passing a oral fiberoptic bronchoscope followed by ETT.This should cause minimal trauma to any soft tissue.offcourse it goes without saying you need to ensure maximum patient cooperation,good topicalisation with LA and an experienced and skilled intubator.

I would prefer not to use anything that will penetrate tissue, and I agree with your concerns about nasotracheal intubation potentially causing serious nose bleed, especially in dry climates such as we have in Denver and Tucson. I think that there is nothing wrong with doing a fiberoptic oral intubation attempt in these patients if clinical stability permits. If the patient is unstable and you need to manage the airway, then as already stated above my a number of comments, bite the bullet and do a surgical cricothyrotomy.

There is another concern in patients with ankylosed in flexion cervical spine - the so-called "chin at chest" deformity that will provide additional difficulties in doing crycothyrotomy. Perhaps in similar cases  a distally done tracheostomy should be concidered. 

Michael Ward gives my first answer - field blocks or peripheral nerve blocks depending on the surgical site.  i disagree with Dr. Ward in re the potential for tracheal and nasal hemorrhage is high with the retrograde technique.  If the retrograde attempt fails, you have already located the site for the cricothyrotomy.