An Alternative and Efficient Topicalization Technique for the Difficult Airway: A Case Series

Effective airway topicalization is essential for awake tracheal fiberoptic intubation (ATI) in patients with a difficult airway. Traditional methods often result in inadequate anesthesia at the laryngeal inlet, leading to patient discomfort, procedural difficulty, and excessive local anesthetic (LA) use. This case series introduces a novel, resource-efficient topicalization technique using standard operating theatre equipment. It employs two custom assemblies: one targets LA precisely at the laryngeal inlet, while the second augments spray-as-you-go application with supplemental airflow to enhance LA dispersion, oxygenation, and secretion clearance. Currently, no existing device combines all of these functions into a single, integrated system. In four varied cases, including patients with obstructive airway pathology, cystic hygroma, and oropharyngeal tumors, this method enabled smooth, first-attempt ATI with minimal patient discomfort. This demonstrates a feasible, effective, and procedurally efficient technique. A custom device (Avi Airway) is under development at our institution to integrate these features into a streamlined system. Further studies are planned to assess its broader clinical utility.