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Ankylosing Spondylitis Airway — FRCA Final MCQ

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ModerateAirway ManagementAnkylosing Spondylitis AirwayFRCA Final

A 30-year-old man with ankylosing spondylitis requires emergency appendicectomy. He is cooperative and has no stridor or other evidence of upper-airway obstruction. Airway assessment demonstrates severe fixed cervical flexion, markedly restricted cervical movement and a Mallampati class IV view. An experienced anaesthetist and full difficult-airway equipment are available. Which is the most appropriate primary plan for securing his airway?

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Correct answer: E — Awake flexible bronchoscopic tracheal intubation

The best answer is **B, awake flexible bronchoscopic tracheal intubation**. Severe fixed cervical flexion and a Mallampati IV view predict difficult laryngoscopy, while ankylosed cervical vertebrae are vulnerable to injury from manipulation. An awake technique maintains spontaneous ventilation until tracheal placement is confirmed and flexible bronchoscopy permits intubation with minimal neck movement. DAS guidance supports considering awake tracheal intubation in an anticipated difficult airway; both flexible bronchoscopy and videolaryngoscopy can be used, so fibreoptic intubation should not be described universally as the “gold standard.” Blind nasal intubation is traumatic and unreliable. Induction followed by direct laryngoscopy risks loss of airway control. Tracheostomy under general anaesthesia does not manage the induction risk and is not first-line without obstructing pathology. A supraglottic airway is not an appropriate definitive airway for emergency laparoscopic abdominal surgery with aspiration risk.

Reference: Difficult Airway Society. Ahmad I et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020;75:509–528. https://pubmed.ncbi.nlm.nih.gov/31729018/