The patient was a 30-year-old, 60 kg male who presented several days after sustaining blunt trauma to the left side of his jaw. The patient was playing football and was elbowed in this area. He immediately had swelling and pain in the left mandibular area adjacent to his ear. He had limited jaw mobility, which greatly exacerbated his pain and was only able to tolerate eating soft foods. On admission, the patient had obvious facial swelling to the left side of his face and dental misalignment was noted. A maxillofacial CT scan was obtained which showed an acute left mandibular fracture just inferior to the condyles. The remaining facial bones were intact without acute fracture. Also observed on the CT scan were narrow nasal passages and a leftward deviated nasal septum. Otolaryngology scheduled surgical intervention for fracture reduction and maxillomandibular fixation. 
Evaluation preoperatively showed poor mouth opening secondary to pain. He was appointed a Mallampati score of II and was estimated to have a thyromental distance greater than 6 cm. Nasotracheal intubation was the proposed means of airway control due to the necessity of maxillomandibular fixation thus precluding orotracheal intubation. The patient demonstrated patency of both nares and provided no history of nasal trauma or knowledge of any nasal septal deviation. The patient was premedicated with midazolam 2 mg intravenously and fentanyl 100 mcg intravenously. All standard monitors were applied. The patient received 3 sprays of oxymetazoline to each naris. Anesthesia was induced with propofol 200 mg intravenously and fentanyl 150 mcg intravenously. After successful mask ventilation, succinylcholine 100 mg was administered intravenously. Easy mask ventilation was achieved with confirmation of end-tidal CO2 and adequate oxygenation. A nasal RAE endotracheal tube was then introduced into the right naris with immediate resistance. Repositioning of the angle of entry did not overcome the difficult passage, nor did downsizing to a smaller nasal RAE endotracheal tube. Intubation via the right naris was aborted and intubation through the left naris was attempted. However, immediate resistance was again experienced and it was felt at this time that nasotracheal intubation was not going to be possible. The patient was mask ventilated again and was then intubated orally with an 8.0 endotracheal tube. On direct laryngoscopy, miniscule amounts of blood were noted in the patient's pharynx from the nasal trauma sustained during the initial intubation attempts. Bilateral breath sounds and end-tidal CO2 were confirmed. The surgeon then made a small, approximately 2 cm incision in the right submental region and bluntly dissected through the floor of the mouth with Kelly forceps. The ventilator was then briefly disconnected and the endotracheal tube and pilot balloon were pulled through the submental tunnel via the Kelly forceps. The circuit was reconnected, end-tidal CO2 and bilateral breath sounds were confirmed, and direct laryngoscopy was repeated to confirm tube placement. The supraglottic and oropharyngeal areas were adequately suctioned and the surgeons proceeded with the case. Anesthesia was successfully maintained with inhaled isoflurane. The patient's initial airway pressures while orotracheally intubated were consistently 15-16 cm H2O. However, after tunneling the endotracheal tube through the floor of the mouth, peak pressures increased to 25-30 cm H2O. These increased pressures were felt to be secondary to the acute bend that the tube was required to make in the oropharynx. No other issues with ventilation or oxygenation were encountered throughout the case. The surgical team inserted four, 8 mm self-drilling screws into the patient's maxilla and mandible and used 26-gauge wire to achieve properly aligned dental occlusion. The submental incision was then infiltrated with lidocaine and epinephrine. A soft suction catheter was used to attempt to remove as much secretions as possible from the patient's pharynx. The inhalational agent was turned off and the patient awakened. The surgical team was standing by with wire cutters in hand should airway compromise had been encountered. It was felt that the patient was adequately awake when he was able to generate sufficient and consistent tidal volumes, follow commands to squeeze fingers and maintain a head lift when asked. At this time the cuff was deflated and the endotracheal tube was slowly removed through the submental tunnel. The surgical team closed the submental incision, first with 4-0 Vicryl for the subcutaneous plane and a 5-0 fast absorbable suture for the skin. The patient maintained excellent ventilation and oxygenation and at no time experienced any airway compromise or oxygen desaturation. He was taken to the postanesthesia care unit in excellent condition.