Management of a difficult airway for multispace infection of the floor of the mouth: A case report.

rationaleMultispace infections of the floor of the mouth are rapidly progressive, life-threatening conditions that often result in airway compromise due to anatomical distortion and trismus. Managing the airway in such cases is particularly challenging, especially when compounded by systemic metabolic derangements such as diabetic ketoacidosis. This case highlights a novel and safe approach to securing the airway in a critically ill patient when conventional methods are contraindicated. PATIENT CONCERNS: A 27-year-old male with type 1 diabetes mellitus presented with diabetic ketoacidosis (pH 6.996, glucose 22.2 mmol/ L), severe trismus (interincisal distance <1.5 cm), maxillofacial swelling, cervical rigidity and dyspnea. Magnetic resonance imaging confirmed multispace infection with cervical abscess, mediastinal extension and pleural effusion. DIAGNOSES: Life-threatening multispace infection of the floor of the mouth complicated by diabetic ketoacidosis, cervical abscess, and imminent airway obstruction requiring emergency surgical drainage and tracheostomy.

interventionsAwake tracheal intubation (ATI) was performed under conscious sedation (dexmedetomidine and remifentanil) with spontaneous ventilation preserved. Sequential topical airway anesthesia (2% lidocaine) was administered via an epidural catheter secured to a fiberoptic bronchoscope. Following successful ATI, general anesthesia was induced for incision, drainage of abscesses, and tracheostomy. OUTCOMES: ATI was successfully completed without episodes of hypoxia, hemodynamic instability, or patient discomfort. Surgical incision and drainage of submental and sublingual abscesses, along with tracheostomy, were completed within 65 minutes under general anesthesia. Postoperatively, the patient regained spontaneous breathing on day 1, with a total of 76 mL of purulent drainage recorded. The patient was discharged on postoperative day 21 in stable clinical condition, with no signs of residual infection. No adverse events related to airway management were observed. LESSONS: This is the first reported case of diabetic ketoacidosis with severe trismus and multispace infection managed by ATI using an epidural catheter fixed to a channel-less fiberoptic bronchoscope for sequential topical anesthesia. The technique offers an alternative when standard devices are impossible or contraindicated.