A 48-year-old male with a history of laryngeal papillomatosis and previous difficult intubation (Cormack–Lehane Grade 3) presents for elective laryngeal microsurgery. Awake fiberoptic intubation is planned. During the procedure, the scope is advanced into the larynx and the operator notes significant subglottic narrowing with papillomatous tissue. Which of the following is the MOST appropriate immediate action to optimize visualization and reduce the risk of tube malposition?

Explanation

## Optimal Management of Difficult Airway with Laryngeal Pathology **Key Point:** In awake fiberoptic intubation complicated by significant subglottic narrowing due to papillomatous tissue, topical vasoconstrictors (epinephrine) are the standard first-line intervention to reduce mucosal edema and improve airway diameter without abandoning the awake approach. **Clinical Reasoning:** - **Why epinephrine works:** Topical epinephrine (1:10,000 concentration) causes mucosal vasoconstriction, reducing edema and tissue bulk. This is particularly effective in laryngeal pathology where mucosal swelling contributes to obstruction. - **Timing:** A 2–3 minute interval allows adequate vasoconstriction before reattempting visualization. - **Preserves airway control:** Awake fiberoptic intubation maintains spontaneous ventilation and airway reflexes; switching to general anesthesia risks loss of airway in a patient with known difficult anatomy. - **Standard practice:** Topical epinephrine is recommended in difficult airway algorithms (ASA, Difficult Airway Society) for managing laryngeal edema or mucosal hypertrophy during awake intubation. **High-Yield Fact:** Epinephrine concentration for topical airway use is 1:10,000 (0.01%); higher concentrations risk systemic absorption and arrhythmias. **Mnemonic:** VASE (Vasoconstrictors, Anesthetics, Shrink tissue, Ease intubation) — use vasoconstrictors first when obstruction is due to edema/swelling.