Approaches to difficult airway management in a patient with ankylosing spondylitis and severe cervical spine deformities.

INTRODUCTION AND IMPORTANCE

Ankylosing spondylitis (AS) is a chronic inflammatory disease that leads to progressive spinal rigidity and severe cervical deformities, making airway management highly challenging for anesthesiologists.

CASE PRESENTATION

We report a case of a 45-year-old patient with severe AS complicated by a cervical spine fracture and extreme cervicothoracic kyphosis. Due to a significantly limited mouth opening and an unassessable thyromental distance, conventional intubation methods were not feasible. Awake fiberoptic nasotracheal intubation, facilitated by remifentanil infusion and topical anesthesia, was successfully performed while maintaining spontaneous breathing. However, despite effective airway management, the patient later developed a massive pulmonary embolism leading to cardiac arrest.

CLINICAL DISCUSSION

Airway management in AS patients requires a tailored approach based on anatomical limitations. Fiberoptic intubation remains the gold standard in severe cases, ensuring minimal cervical movement and optimal visualization. Alternative methods, such as videolaryngoscopy and laryngeal mask airway placement, may be useful in selected cases. However, in cases of extreme deformity, tracheostomy remains a last-resort option.

CONCLUSION

Awake fiberoptic intubation remains the safest approach in severe AS cases with cervical spine involvement, minimizing the risk of spinal cord injury and ensuring airway security.