Difficult Tracheal Intubation in Adult Patients Undergoing Head and Neck Surgery: Predictive Factors and Airway Management in a Resource-Limited Setting

Background: Difficult tracheal intubation remains a major challenge in anesthesia because of the risk of hypoxemia, airway trauma, and failure to secure the airway. These challenges are particularly pronounced during head and neck surgery and in resource-limited settings where advanced airway devices are often unavailable. This study aimed to determine the frequency of difficult tracheal intubation, identify its main predictive factors, and describe its management among adults undergoing head and neck surgery in a resource-limited university hospital.

Methods: A prospective, observational, descriptive study was conducted over a 30-month period (January 2017 to June 2020) at the University Hospital Centre Professor Zafisaona Gabriel, Mahajanga, Madagascar. Adult patients undergoing ENT or maxillofacial surgery under general anesthesia with tracheal intubation were included. Preoperative predictors of difficult intubation were systematically assessed. Airway management strategies and clinical outcomes were recorded.

Results: Among 178 included patients, difficult tracheal intubation was predicted in 73 (41.0%) and confirmed in 29 (39.7%) of these patients. Restricted mouth opening was the most frequent predictive factor (42.4%), followed by Mallampati class III–IV (32.8%). Maxillofacial surgery accounted for 67.1% of predicted difficult intubations. The mean number of intubation attempts was 4.2 ± 1.3, and the mean intubation time was 6.0 minutes. The Eschmann tracheal introducer was the most commonly used adjunct (55.2%). Impossible intubation occurred in four patients (13.8%); two required tracheostomy, whereas two were successfully managed by maintaining oxygenation until awakening. Rescue airway management included blind nasotracheal intubation, two-handed face-mask ventilation, and laryngeal mask airway insertion.

Conclusion: Difficult tracheal intubation is common during adult head and neck surgery in our setting. Careful preoperative airway assessment and the rational use of available airway adjuncts remain essential to optimize airway management where advanced airway equipment is unavailable. Improving provider training and expanding access to dedicated airway devices may further enhance patient safety.