The tortuous airway: Anatomical variability requiring off centre tracheostomy

Abstract Can't intubate can't oxygenate (CICO) is a cause of concern for both the anaesthetist and airway surgeon. Anatomical variability in the upper airway can result in failed attempts at endotracheal intubation and subsequently a challenging surgical airway. We present the case of a 74 year old man admitted with pneumonia on a background history of kyphoscoliosis and rheumatoid arthritis who required emergency ventilation due to an acute respiratory deterioration. After several failed attempts at intubation and difficulty maintaining oxygenation using supraglottic airway devices the decision to proceed to a surgical airway was made. During the operation the patient's trachea was noted to be 5 cm right of midline and tracheostomy tube was inserted successfully.