Awake nasal fiberoptic intubation for pediatric maxillary AVM bleeding: observations from two cases

Children with acute bleeding from a maxillary intraosseous arteriovenous malformation (AVM) may depend on continuous external compression of the intraoral bleeding site—usually gauze packing over the maxillary alveolus—for hemostasis. Airway maneuvers that interrupt that compression can precipitate severe re-bleeding. In Case 1, rapid sequence induction without a plan to preserve pack compression led to loss of the patient’s ability to maintain voluntary biting of gauze. The pack was then removed to allow laryngoscopy, and torrential arterial hemorrhage and hemorrhagic shock followed. In Case 2, an oral surgeon kept two fingers on the pack throughout induction, which precluded positive-pressure mask ventilation. Dexmedetomidine-assisted awake nasal fiberoptic intubation was performed, organized around the Difficult Airway Society sTOP headings (Sedation, Topicalisation, Oxygenation, and Performance), while spontaneous breathing and compression were preserved. Intubation was completed in 23 min without significant bleeding, desaturation, or hemodynamic instability. These two cases suggest that, in a cooperative school-age child with bleeding maxillary intraosseous AVM, dexmedetomidine-assisted awake nasal fiberoptic intubation under continuous manual compression may be a feasible way to secure the airway without interrupting intraoral hemostasis. The observations are limited by the small number of patients and by differences in baseline severity. This is a retrospective case series. Clinical trial number: not applicable.