Difficult Airway Management After Refusal of Awake Fibreoptic Intubation in a Giant Facial Plexiform Neurofibroma

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterised by café-au-lait macules, cutaneous neurofibromas, and plexiform neurofibromas, which may extensively infiltrate surrounding tissues and create significant airway challenges during anaesthesia. We report the anaesthetic management of a 33-year-old man with a giant left-sided facial plexiform neurofibroma involving the glabella, eyelid, cheek, lips, chin, and hard palate undergoing his third staged debulking surgery. Although awake fibreoptic intubation was recommended, the patient declined the procedure. A bridging airway strategy was therefore adopted using an i-gel (Intersurgical, Wokingham, UK) supraglottic airway to establish ventilation, followed by fibreoptic-guided tracheal intubation through the device. Anaesthesia and surgery were completed uneventfully with stable haemodynamics, and the patient was extubated awake before transfer to the intensive care unit. This case demonstrates that an i-gel-assisted fibreoptic intubation technique is a safe and effective alternative when awake fibreoptic intubation is refused in patients with anticipated difficult airways due to giant facial plexiform neurofibromas.