Awake videolaryngoscopy with high-flow nasal oxygen for odontogenic facial–periorbital cellulitis with abscess and trismus: a case report

Abstract

Background: Odontogenic infections that extend into the cervicofacial and periorbital regions can create a critical airway challenge. Marked swelling and trismus frequently distort the anatomy, making bag–mask ventilation unreliable and complicating laryngoscopy. In this setting, induction of general anesthesia carries the risk of losing both ventilation and intubation. An awake approach that preserves spontaneous breathing and ensures continuous oxygenation provides a safer path to airway control.

Case Presentation: A 61-year-old woman developed progressive left facial and periorbital swelling with abscess formation two days after dental extraction. On arrival, she had severe trismus, with an interincisor distance of about 1.5 cm. The team planned an awake intubation. Topical anesthesia was achieved using 4% lidocaine in multiple forms, and dexmedetomidine was titrated to maintain cooperative sedation (RASS −2 to −1). High-flow nasal oxygen was delivered via high-flow nasal oxygen, starting at 30 L/min and increased to 60 L/min with FiO₂ 1.0, maintained throughout preparation and laryngoscopy. Using a C-MAC videolaryngoscope with a hyper-angulated blade, a partial but adequate view of the glottis (POGO 60–70%) was obtained. A bougie was advanced under direct vision, and a 7.0-mm cuffed endotracheal tube was successfully railroaded on the first attempt. Oxygen saturation remained ≥98% with stable hemodynamics. The abscess was surgically drained, and the patient was extubated safely after 36 hours. She was discharged home on the fifth postoperative day in good condition.

Conclusion: For patients with airway compromise due to infective trismus, awake videolaryngoscopy supported by continuous high-flow nasal oxygenation and planned use of adjuncts such as a bougie can facilitate controlled, atraumatic intubation. This combination minimizes the risk of desaturation and maximizes the chance of first-pass success

Keywords: Facial cellulitis; difficult airway; videolaryngoscopy; high-flow nasal oxygenation; awake intubation; multidisciplinary airway management

Citation: Chrishaille M, Manickam A, Kodali RK. Awake videolaryngoscopy with high-flow nasal oxygenation for odontogenic facial–periorbital cellulitis with abscess and trismus: a case report. Anaesth. pain intensive care 2026;30(1):124-128. DOI: 10.35975/apic.v30i1.3087

Received: August 02, 2025; Revised: September 27, 2025; Accepted: January 18, 2026