Ultrasound-Guided Airway Mapping and Regional Blocks in Post-radiation Cervicofacial Contractures: A Case Report

Post-radiation cervicofacial contractures can create major airway management challenges due to anatomical distortion and vascular displacement. We report the case of a 47-year-old woman (American Society of Anesthesiologists (ASA) physical status III), with a history of right hemimandibulectomy and adjuvant radiotherapy for oral squamous cell carcinoma three years prior, presenting for contracture release, with severe trismus (mouth opening <1 fingerbreadth), fixed neck flexion, leftward tracheal deviation, lateralised carotid arteries, and severe malnutrition (BMI 16.2 kg/m²). Preoperative high-frequency ultrasound (6-13 MHz linear probe) enabled the mapping of the trachea, cricoid cartilage, thyroid cartilage, cricothyroid membrane, hyoid bone, bilateral carotid arteries, and internal jugular veins and the identification of displaced critical structures. Under real-time ultrasound guidance, bilateral superior laryngeal nerve blocks and a transtracheal block were performed using a total lignocaine dose of 280 mg (4 mg/kg), avoiding displaced vasculature. Awake nasal fibreoptic intubation with a 7 mm cuffed endotracheal tube was completed uneventfully, after which general anaesthesia proceeded without incident and the patient was extubated at the end of surgery after meeting standard clinical criteria. This case suggests that ultrasound-guided airway blocks, combined with preoperative airway mapping, may facilitate airway topicalisation and help reduce the risk of vascular injury in selected post-radiation patients with distorted anatomy.