Retrograde Lidocaine Spray for Awake Extubation in Pediatric ENT Surgery: Optimizing Tonsillectomy and Adenoidectomy Outcomes.

Laryngeal edema, a frequent manifestation of acute inflammation, is particularly significant due to the potential obstruction of the laryngeal orifice caused by swelling of the epiglottis and vocal cords. This presents as a risk factor that can lead to severe airway obstruction. Traditionally, deep extubation is the preferred form of extubation because it is more comfortable for the patient, eliminates the airway reflexes, and minimizes the risk of laryngeal edema. Difficult mask ventilation (DMV), characterized by an unassisted anesthesiologist's inability to maintain oxygen saturation levels above 92% or to prevent or correct signs of inadequate ventilation during positive-pressure mask ventilation under general anesthesia, necessitates an awake extubation approach. In the following case, combining the need to minimize airway reflexes through a deep extubation with the need for an awake intubation required an alternative method. Our patient is a 10-year-old male who presented with obstructive sleep apnea and tonsillar hypertrophy. The patient had a history of snoring and difficult intubation (three attempts), classifying him as a DMV risk. However, due to the difficult intubation, there was concern for laryngeal edema following the procedure that would necessitate a deep extubation. To effectively combine the two procedures, a retrograde lidocaine spray was used to numb the airway, which would allow for awake extubation without the associated coughing and bucking. Deep extubation is a common anesthetic technique used in laryngeal surgeries, but it is often not an option for high-risk patients. For such patients, awake extubation is an alternative. In our case, our patient was at high risk for laryngeal edema. In awake extubation, lidocaine spray is used for minimal coughing and bucking because it numbs the upper airway and allows the patient to tolerate the breathing tube without stimulating the gag reflex. The use of retrograde lidocaine spray for awake extubation in patients at high risk for laryngeal edema presents a promising alternative to traditional methods. This case demonstrates the effectiveness of retrograde lidocaine spray in awake extubation to reduce coughing and bucking by numbing the upper airway in a DMV situation while also avoiding complications in a high-risk patient.