We read with great interest the paper by Slater and Bhatia . In patients such as the one described in which surgery could represent a potential physical conflict for airway management, airway preoperative evaluation should be rigorous and precise, so as to allow planning of first-line strategy and of a ‘plan B’ in case of failure. In this case, no such information was available for the reader except for an ‘unremarkable’ preanaesthetic evaluation and a generic ‘some limitations of mouth opening’. According to the Italian Difficult Airway Management Guidelines , and representing general commonsense, mouth opening limitation represents, even as an isolated finding, a prediction of potential major difficulty requiring very careful considerations and strategies.
In fact, a reduction in mouth opening, especially in the presence of limited mandibular protrusion, represents a critical step not only for intubation (no space for laryngoscope insertion and/or airway manoeuvres)  but also for ventilation with both face-mask  or laryngeal mask or other extraglottic devices. So, despite this ‘unremarkable’ isolated finding, the safest strategy would have been, in our opinion, awake fibreoptic intubation or, in the event of lack of patient cooperation, by fibreoptic intubation in a sedated but spontaneously breathing patient. This is especially so considering of the concomitant presence of facial deformity due to previous surgery and radiotherapy (before which, presumably, ventilation was uneventful).
Insertion of a laryngeal mask in cases of difficult ventilation is an appropriate choice although it may be inadvisable to remove it to perform laryngoscopy, place it again and then finally remove it before proceeding to an asleep fibreoptic intubation. These manoeuvres could have compromised further ventilation or fibreoptic intubation because of bleeding, secretions or minor pharyngo-laryngeal trauma. Italian guidelines prefer direct vision techniques to blind attempts, though recognizing the value of a bougie or, better, of hollow introducers . Particularly, in this case, fibreoptic intubation via a laryngeal mask using the Aintree® catheter (Cook Critical Care, Bloomington, IN, USA), once the laryngeal mask was placed and ventilation was guaranteed , could have been the best option. Asleep fibreoptic intubation, we believe, could have led to dangerous desaturation, especially if performed in an apnoeic patient without dedicated devices such as a Berman-like cannula or endoscopy mask. We would finally consider protected extubation (such as over an airway exchange catheter under local anaesthesia)  as a strategy for similar cases.
Our message is hopefully clear - might intubation be difficult, guarantee oxygenation first. If either ventilation or intubation is predicted to be difficult, safety first. The fibreoptic awake intubation technique is the definitive choice, particularly in elective situations.
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2. SIAARTI Difficult Airways Study Group. Task Force: Petrini F, Guarino A, Merli G, Sorbello M, Frova G. Recommendations for airway control and difficult airway management. Minerva Anestesiol
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