Elective Front-of-neck Access in Pediatric Airway Emergencies: A Clinical Update

An 8-year-old underwent an elective front-of-neck access for an anticipated cannot-intubate–cannot-ventilate (CICO) scenario; the single-case report documents successful oxygenation and no immediate complications.

Historically, clinicians attempted primary intubation and treated FONA as a last-resort rescue—an approach that can allow rapid decompensation in small children with fixed obstructing lesions. The reported preemptive strategy prioritized anticipation, team preparation, and anatomical landmark marking to reduce uncontrolled airway loss. The report emphasizes declaring roles and rehearsing steps before induction. For select children with obstructing lesions, preemptive FONA planning lowers the likelihood of an emergency CICO.

Key procedural steps began with high-flow nasal oxygenation and preoxygenation, judicious anesthetic choice to preserve spontaneous ventilation, pre-marking cricothyroid and tracheostomy landmarks, preparing a needle cricothyrotomy kit and surgical instruments, assigning clear roles for airway operator and assistant, and arranging definitive care and ICU transfer. Performed in sequence, elective FONA becomes a predictable, controllable bridge to definitive airway management.

In the case, immediate oxygenation was achieved via cannula, the mass was excised, and the child was transferred to paediatric intensive care for monitored recovery. Short-term priorities after FONA include stabilizing oxygenation, achieving hemostasis, and arranging early airway imaging or bronchoscopy to assess injury or residual obstruction. Potential complications—bleeding, infection, and late subglottic or tracheal stenosis—are low-frequency but clinically important and warrant early detection and planned surveillance to reduce morbidity.

Elective FONA shows that, with meticulous preparation and clear roles, it can serve as a planned bridge in anticipated pediatric CICO from obstructing tumors. The approach merits discussion within multidisciplinary planning for complex pediatric airway lesions.

Key Takeaways:

• Elective FONA can be used proactively for anticipated CICO in children with obstructing tumors.
• Frontline pediatric anesthetists, surgeons, and emergency teams managing anatomically obstructing airway lesions.
• Integrate preoperative FONA planning, role assignment, and ICU pathways into airway protocols.