Expedited awake tracheal intubation using ropivacaine topicalisation for the evacuation of a postoperative neck haematoma in the presence of lignocaine allergy

Progressive airway compromise from a neck haematoma is a feared complication of head and neck surgery that can rapidly lead to death if not urgently intervened upon. We report a case of a patient developing a progressively expanding neck haematoma on the first postoperative night after parotidectomy and neck dissection for malignancy. Although he did not have respiratory compromise or stridor, ultrasound examination of his airway revealed marked tracheal deviation, and flexible nasoendoscopy showed significant supraglottic swelling. The decision was made for an awake fibreoptic intubation; however, a complicating factor was a history of lignocaine allergy. This case report describes the unconventional use of atomised ropivacaine in a concentration of 0.5% for topicalisation of the airway. Along with conscious sedation with remifentanil, ropivacaine provided excellent conditions for awake intubation, following which a significant amount of blood was evacuated from the face and neck.