Limited Nasal Intubation Route After Pharyngeal Flap Surgery: A Case Report

Challenges may occur during nasal intubation in patients with a history of cleft lip and palate who undergo orthognathic surgery. A 22-year-old man with a history of cleft lip and palate along with a pharyngeal flap was scheduled to undergo bilateral sagittal split ramus osteotomy. Due to the planned surgery, nasal intubation was requested; however, adhesions between the right inferior nasal turbinate and the nasal septum made intubation through the right nasal cavity unfeasible. Since nasal intubation was time-consuming, the airway was first secured by oral intubation. Under fiberoptic bronchoscopy guidance, a nasotracheal tube was inserted into the left nasal cavity and directed through the left pharyngeal flap orifice. After surgery, the airway was again resecured orally, the nasal tube was removed, and the airway was assessed for complications prior to emergence and extubation. A comprehensive preoperative assessment, simulation using imaging and nasopharyngeal endoscopy, and creation of intubation strategies and validation techniques helped ensure pharyngeal flap integrity and appropriate airway management during this challenging anesthetic case.