Difficult airway management in giant mandibular ameloblastoma: a case report of awake fiberoptic-guided retrograde intubation.

Introduction: Difficult airway management remains a major challenge in anesthesiology, particularly in patients with large head and neck tumors. Giant mandibular ameloblastoma may cause massive orofacial deformity and distortion of the oropharyngeal anatomy, thereby increasing the risk of failed mask ventilation and intubation, even with fiberoptic assistance. Case Presentation: A 55-year-old man with a giant mandibular ameloblastoma was scheduled for total mandibulectomy with bilateral free fibula flap reconstruction. Preoperative evaluation revealed predictors of a difficult airway due to a large orofacial mass, restricted mouth opening, facial deformity, and Mallampati score of 3. The anesthesia team planned awake retrograde intubation guided by fiberoptic bronchoscopy, with awake tracheostomy as a backup strategy. The procedure was successfully performed without complications, allowing surgery to proceed safely, and the patient was monitored postoperatively without signs of respiratory compromise. Discussion: This case highlights the importance of innovative airway strategies in the management of anticipated difficult airway. The combination of retrograde and fiberoptic intubation proved effective in overcoming the limitations of each technique when used alone, while minimizing airway trauma and reducing the risk of hypoxia. Careful preoperative planning, preparation of backup strategies, and multidisciplinary collaboration were key to success. Conclusion: Awake fiberoptic-guided retrograde intubation can serve as a safe and effective option for managing difficult airways caused by giant mandibular ameloblastoma. Long-term follow-up remains essential to evaluate airway function, postoperative recovery, and potential complications.