DOI: https://doi.org/10.36347/sjmcr.2025.v13i11.035

Pages: 2815-2819c

Background: Extensive cervicofacial post burn contracture (PBC) can render mask ventilation, supraglottic airway placement, tracheal intubation, and eFONA simultaneously difficult. While awake tracheal intubation (ATI) is recommended, extreme scarring may prevent classic ATI. We describe a staged, oxygenation first approach: limited release under local anesthesia to create access, objective confirmation of ventilatability with a second generation supraglottic device, then awake fiberoptic intubation (FOI) under cooperative sedation. Case: A 24 year old man with severe cervicofacial PBC, fixed neck flexion, and microstomia had CT showing soft tissue thickening without intrinsic airway stenosis. Under monitored anesthesia care with dexmedetomidine–remifentanil, continuous nasal oxygen, capnography, and staged topicalization (lidocaine governed to ≤9 mg/kg lean body weight with dose summation), a limited mentosternal release was performed. An i gel® confirmed effective positive pressure ventilation. The device was removed and oral FOI placed a 6.5mm reinforced tube without desaturation. Definitive release and grafting proceeded uneventfully (9 h). He remained intubated overnight for edema surveillance and underwent planned extubation on day 1 without complications. Conclusion: In extreme PBC, MAC assisted “release before intubation,” combined with disciplined oxygenation, topicalization, and predefined rescue, enables safe awake FOI and definitive surgery, providing a pragmatic, guideline concordant option when classic ATI is not feasible.