Successful Awake Blind Nasal Intubation for Airway Management of a Giant Parapharyngeal Space Tumor in a Resource-Limited Setting.

Introduction: Parapharyngeal space (PPS) tumors are rare and account for approximately 0.5% of all head and neck tumors. Their close proximity to the upper airway can result in significant anatomical distortions, making airway management challenging. Awake tracheal intubation is recommended when a difficult airway is anticipated; however, advanced airway devices such as flexible fiberoptic bronchoscopes and videolaryngoscopes may not be available in low-resource settings. Awake blind nasal intubation (ABNI), although rarely practiced today, may be a feasible alternative in carefully selected patients. Objective: We report successful airway management with ABNI in a patient with PPS tumor in a resource-limited setting. Case Presentation: A 45-year-old man presented with a progressively enlarging giant PPS tumor, associated with dysphagia, snoring, and oral airway obstruction. Preoperative airway evaluation revealed Mallampati Class III, preserved mouth opening, and unrestricted cervical spine mobility; however, the large intraoral mass suggested a potentially difficult airway. Because fiberoptic bronchoscopy and videolaryngoscopy were unavailable, ABNI was planned while maintaining spontaneous ventilation, and emergency surgical tracheostomy was performed as a rescue strategy. Airway topicalization was achieved using 2% lidocaine gargle and intravenous lidocaine, together with nasal vasoconstriction using adrenaline-soaked gauze. A lubricated 6.0-mm cuffed endotracheal tube was successfully inserted through the left nostril on the first attempt, without hypoxemia, airway trauma, or hemodynamic instability. General anesthesia was administered uneventfully, and complete tumor excision was successfully performed. The patient recovered without perioperative complications and was discharged on postoperative day six. Conclusion: This case demonstrates that ABNI may represent a practical alternative for selected patients with anticipated difficult airways due to PPS tumors when advanced airway equipment is unavailable. Careful patient selection, meticulous airway assessment, adequate topical anesthesia, maintenance of spontaneous ventilation, and preparation for emergency surgical airway management remain essential. Although this case illustrates technical feasibility, broader conclusions regarding safety or effectiveness cannot be drawn from a single case.