Airway Management in Otolaryngology and Head and Neck Surgery: A Narrative Review of Current Techniques and Considerations

CLINICAL QUESTION

Which contemporary airway techniques and planning principles are most relevant to routine and emergency otolaryngology and head and neck surgery?

BOTTOM LINE

Modern ENT airway management depends on multidisciplinary planning, specialized equipment, and procedure-specific expertise; however, difficult-airway guidelines are still developed mainly within anesthesiology because otolaryngology-specific literature remains limited.

BACKGROUND: Airway management in otolaryngology is complicated by shared surgical and anesthetic access, airway pathology, altered anatomy after treatment, bleeding, and the need for unobstructed operative exposure. Patients undergoing ENT procedures also have a disproportionately high risk of major airway complications and emergency surgical airway intervention.

STUDY DESIGN: Narrative review of contemporary airway-management techniques in ENT surgery, supplemented by a structured search of PubMed, EMBASE, and Cochrane databases for difficult-airway publications from January 2015 through January 2025.

SETTING: Published literature addressing elective and emergency airway management in otolaryngology, anesthesiology, pediatrics, trauma, and emergency medicine.

SYNOPSIS: The search initially identified 4,641 airway-related articles. After applying the 10-year date restriction and screening, 967 publications were reviewed across 82 publishers. Most appeared in anesthesiology journals (301; 31%), while only eight (0.8%) were published in otolaryngology journals, highlighting limited ENT-specific difficult-airway guidance. The review describes standard, reinforced, microlaryngoscopy, laser-resistant, Ring-Adair-Elwyn, and nerve-monitoring endotracheal tubes, emphasizing trade-offs among airway security, surgical access, resistance, positioning, and fire risk. Jet ventilation can improve exposure during laryngeal surgery but requires expertise because carbon dioxide monitoring may be difficult and complications include hypercapnia, gas trapping, and barotrauma. High-flow nasal oxygen and transnasal humidified rapid-insufflation ventilatory exchange can extend apneic oxygenation and provide a bridge during difficult airway management, although they require a patent upper airway and are unsuitable during laser or diathermy use. Supraglottic devices may support routine or rescue oxygenation, with second-generation devices offering improved seals and gastric drainage. The authors also review pediatric bronchoscopy, foreign body retrieval, bleeding airways, trauma, stridor, and tubeless-field surgery. Videolaryngoscopy may improve visualization in selected difficult or trauma airways, while awake tracheal intubation remains an important option when severe difficulty is anticipated and expertise is available. Emergency front-of-neck access should be planned as a rescue strategy rather than treated as a universal first-line approach.

Limitations of this review include narrative article selection, no formal quality assessment, heterogeneous evidence, and differences in institutional equipment and expertise.

CITATION: Bola S, et al. Airway management in otolaryngology and head and neck surgery: a narrative review of current techniques and considerations. J Clin Med. 2025;14:4717. doi:10.3390/jcm14134717.