A 26yr old male patient presented with hypo-pharyngeal stricture secondary to corrosive ingestion. He was posted for laser assisted stricture release under general anesthesia. After 4% lidocaine nebulization and 10% lidocaineaerosolization, an awake direct laryngoscopic examination was performed. There was hypopharyngeal stricture with a very small opening, through which larynx was not visualized. As fiberoptic intubation would be difficult (cork in bottle effect) and tracheostomy is associated with significant morbidity, a plan was made to widen the stricture with laser under local anesthesia. Surgeons were alerted about the need of tracheostomy in event of respiratory distress.

Under local anaesthesia, the hypopharyngeal stricture was widened till the posterior commissure was visualised. Further attempts were abandoned due to patient's distress.

Sevoflurane induction was commenced after adequate preoxygenation. Spontaneous ventilation was preserved. Due to the still distorted anatomy, inserting an endotracheal tube or bougie through the stricture would have obscured vision. Hence, a 0° endoscope was introduced through the now enlarged opening. It guided a size 5mm uncuffed endotracheal tube into the larynx. After surgery, patient was extubated uneventfully.

Conclusion: It is important to assess altered airway anatomy during preoperative work up. Corrosive strictures can cause unpredictable distortion of airway. Careful planning and input by experienced airway surgical colleagues are invaluable in successful airway surgery.