J Oral Maxillofac Surg

69:1608-1612, 2011

Dexmedetomidine Sedation for Awake

Fiberoptic Intubation of Patients With
Difficult Airways Due To Severe
Odontogenic Cervicofacial Infections
Barry C. Boyd, DMD, MD,* and Steven J. Sutter, DDS†

Purpose: Odontogenic infections present challenging airway scenarios to surgeons and anesthesiologists.
Among specialists, there is controversy over airway management for those patients with airways made
difficult by trismus and swelling with anatomic impingement and derangement. Awake fiberoptic intubation
has achieved favor in the oral and maxillofacial surgery and anesthesiology communities for management of
such difficult airways, but patient comfort and anxiety management with traditional agents may prove
hazardous because of potential suppression of protective mechanisms and respiratory depression.
Patients and Methods: Three cases are presented showing the utility and safety of the use of
dexmedetomidine sedation for presurgical airway instrumentation and insertion in patients with chal-
lenging airways because of severe cervicofacial odontogenic infections.
Results: Dexmedetomidine administration provided safe and effective sedation and anxiolysis for
awake fiberoptic airway instrumentation and airway insertion in patients presenting with severe cervi-
cofacial infections with difficult airways because of anatomic obstruction.
Conclusions: Dexmedetomidine sedation is advocated for use in awake fiberoptic intubation of patients
with cervicofacial infections and difficult airways because of its ability to provide sedation, analgesia,
reversible anterograde amnesia, and anxiolysis without impairment of protective reflexes, respiratory depres-
sion, or hemodynamic compromise. One of the most significant challenges facing oral and maxillofacial
surgeons is the difficult airway. Anatomically compromised airways present unique clinically daunting
situations to both surgeon and anesthesiologist, who are both charged with the provision of safe, effective
preoperative, intraoperative, and postoperative airway management. Among these conditions, odontogenic
infections and patients with head and neck trauma, temporomandibular disorders, orofacial tumors, and
severe craniofacial anomalies present for surgical treatment by the oral and maxillofacial surgeon.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:1608-1612, 2011

Patients with odontogenic infections involving the
potential fascial spaces may often present with sig-
nificant trismus as well as effacement and/or de-
rangement of normal anatomic airway features,
Received from the Department of Oral and Maxillofacial Surgery,
State University of New York at Buffalo, School of Dental Medicine,
Buffalo, NY.
*Clinical Associate Professor.
†Formerly Chief Resident, Currently Private Practice, Oral and
Maxillofacial Surgery, New York, NY.
Address correspondence and reprint requests to Dr Boyd: De-
partment of Oral and Maxillofacial Surgery, State University of New
York at Buffalo, School of Dental Medicine, 3435 Main St, Ste 112
Squire Hall, Buffalo, NY 14214; e-mail: bcboyd@buffalo.edu
© 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6906-0020$36.00/0
doi:10.1016/j.joms.2010.11.004
which may create hazards for standard anesthetic
induction and intubation techniques. Coupled with
potential pre-existing anatomic airway abnormali-
ties and other medical and surgical comorbidities,
these severe odontogenic infections with cervico-
facial extension present unique and often high-risk
airway management scenarios to surgeon and anes-
thesiologist.
Anxiety management for the patient with a difficult
airway can be both challenging and hazardous. Ben-
zodiazepines, short-acting opioids, and ketamine have
traditionally been used for conscious sedation during
airway instrumentation but possess the liabilities of cen-
tral nervous system (CNS) depression and, in the case of
bezodiazepines, opioids, and propofol, respiratory de-
pression. Intravenous lidocaine may be considered for
suppression of upper airway reactivity without sedating
effects.

1608
BOYD AND SUTTER
Several case reports have appeared in the anesthe-
siology literature pertaining to the use of dexmedeto-
midine for sedation of patients requiring awake fiber-
optic intubation. The majority of the cases involved
difficult airways resulting from previous treatment of
head and neck cancer, acute cervical spine fractures,
degenerative disease of the cervical spine, and new
neck masses.1-4 Abdelmalak et al1 published a case
series including 2 patients in whom they documented
airways made difficult by obese body habitus and
obstructive sleep apnea (OSA). One of the OSA pa-
tients had recently been diagnosed with nasopharyn-
geal squamous cell carcinoma and presented for tra-
cheostomy for worsening airway obstruction. The
second OSA patient presented for irrigation and de-
bridement of a submandibular abscess.1 Scher and
Gitlin5 document a difficult airway with a history of
failed intubations given the patient’s Mallampati Class
IV airway, relatively short thyromental distance, and
retruded mandible. In their case the authors adminis-
tered dexmedetomidine with low-dose ketamine be-
cause of its potential to offset bradycardia and hypo-
tension associated with the former agent.5
We present 3 cases with airways made difficult
because of odontogenic cervicofacial infections with
intercurrent swelling, trismus, and pain. Awake fiber-
optic airway management was selected by the sur-
geon in consultation with the attending anesthesiolo-
gists. In all 3 cases laryngeal and vocal cord
visualization was possible with well-sedated patients
without respiratory depression or desaturation. In 2
of the cases fiberoptic intubation proceeded unevent-
fully. In the third the anesthesiologist was unable to
pass the endotracheal tube through the glottis be-
cause of significant edema. This patient was venti-
lated and oxygenated with a laryngeal mask airway
and general anesthesia induced, followed by trache-
ostomy. Postoperatively, none of the patients ex-
pressed either recall of or discomfort during airway
instrumentation.
Patients and Methods
CASE 1
A 24-year-old woman presented to the oral and
maxillofacial surgery clinic 3 days after uncompli-
cated extractions of the maxillary right and left third
molars and mandibular right third molar with chief
complaints of “pain on swallowing and difficulty
opening the mouth.” The patient presented with a
fever accompanied by chills and nausea but denied
vomiting and dyspnea. Extraoral examination findings
were positive for right submandibular edema and
lymphadenopathy with tenderness to palpation. In-
traorally, there was trismus, right buccal vestibular
1609
edema, and right pterygomandibular edema. The
uvula was deviated to the left side, and the tongue and
floor of the mouth were elevated. A computed tomog-
raphy (CT) scan of the soft tissue of the neck and face
was performed with contrast, with evidence of right-
sided submental, submandibular, sublingual, and
pterygomandibular collections of fluid.
The patient was admitted for administration of in-
travenous antibiotics and was taken to the operating
room for incision and drainage. Given the findings of
her Mallampati Class IV airway, the anesthetic plan
included awake fiberoptic intubation with the use of
Precedex (dexmedetomidine; Hospira, Inc, Lake For-
est, IL) as one of the agents. The dexmedetomidine
was infused at 18 mL (4 ␮g/mL) over a period of 15
minutes along with 2 mg of midazolam. The patient
was intubated without complication, with her oxygen
saturation never falling below 97%.
The operation proceeded without incident. The
condition of the patient improved with resolving fe-
ver and a normal white blood cell count, and she was
discharged home 3 days later with oral antibiotics and
was followed closely as an outpatient. She had no
complaints regarding the awake fiberoptic intubation
using dexmedetomidine.
CASE 2
A 54-year-old woman presented to the emergency
department with chief complaints of “pain and swell-
ing” on the right side of her face. She had a dental
crown started on the mandibular right second molar
by a general dentist 1 week before presenting to us.
Her physical examination findings were significant for
right-sided facial asymmetry and a maximum interin-
cisal opening of 25 mm. No obvious intraoral edema
was present, and the tongue and floor of the mouth
were not elevated. She was admitted for administra-
tion of intravenous antibiotics and clinical observa-
tion. A CT scan was performed with contrast of the
face and neck, and no clear evidence of a fluid col-
lection was seen.
Approximately 48 hours later, the patient’s clinical
condition worsened with increased trismus and
odynophagia. A repeat CT scan was performed with
evidence of an abscess in the right masticator space.
The patient was taken to the operating room for
incision, drainage, and extraction of unrestorable
teeth. Awake fiberoptic intubation was selected be-
cause of the severity of the patient’s trismus and her
airway status of Mallampati Class IV. Dexmedetomi-
dine was infused at a rate of 18 mL (4 ␮g/mL) over a
period of 10 minutes along with 2 mg of midazolam.
Awake fiberoptic intubation was completed without
complications.
The extraoral incision, drainage, and extraction of
the mandibular right second and third molars were
1610
performed without complication. The patient re-
mained intubated in the intensive care unit (ICU) for
24 hours until extubation criteria were met. She was
discharged in 6 days taking oral antibiotics and was
followed closely in the outpatient clinic until com-
plete resolution of her trismus. She also had no com-
plaints regarding the awake fiberoptic intubation us-
ing dexmedetomidine.
CASE 3
A 45-year-old woman presented to the outpatient
clinic with complaints of pain, swelling, and fever
after initiation of endodontic treatment for the man-
dibular left second molar. She opted for extraction of
that tooth, which was completed with initiation of
oral clindamycin. The patient presented to the emer-
gency department 24 hours later with complaints of
odynophagia, dysphagia, and dysphonia.
The patient was afebrile on presentation to the
emergency department but had leukocytosis, severe
trismus, an elevated tongue, elevation of the left floor
of the mouth, and a Mallampati Class IV airway. A CT
scan with contrast showed left submandibular, sub-
mental, sublingual, and peripharyngeal space abscess
with constriction of the airway at the supraglottic
level.
The patient was taken to the operating room for
extraoral and intraoral incision and drainage. Awake
fiberoptic intubation was selected, and 25 mL (4 ␮g/
mL) of dexmedetomidine was infused over a period of
1 hour along with 100 ␮g of fentanyl. After numerous
unsuccessful attempts at intubation, because of air-
way stricture at the supraglottic level, she was in-
duced and a laryngeal mask airway was inserted. A
surgical airway was obtained before incision and
drainage. After 72 hours in the ICU, the patient was
successfully decannulated and transferred to a regular
nursing floor. She was discharged home 1 week after
admission with oral antibiotics with outpatient fol-
low-up. She has no recollection of the attempted
fiberoptic intubation.
Discussion
The ␣2 agonists have arisen, which— by virtue of
their very specific CNS activity— have the unique
property of producing sedation without the liability
of central respiratory depression. One study suggests
that the ␣2 agonist dexmedetomidine not only pos-
sesses sedative properties but has amnesic and anal-
gesic properties as well.6
Desirable properties of the benzodiazepines in-
clude sedative-hypnotic, anxiolytic, and anterograde
amnesic capabilities. These agents produce clinical
effects via binding to benzodiazepine binding sites.
Specifically, benzodiazepine binding to sites located
DEXMEDETOMIDINE SEDATION
in the ascending reticular activating system and the
cerebral cortices produces sedation. Benzodiazepine
binding to sites in the limbic system is responsible for
anxiolysis. Amnesic and anticonvulsant effects are as-
sociated with benzodiazepine activity in the temporal
lobe sites. The use of midazolam for preinduction
sedation and anxiolysis for airway instrumentation in
awake intubation has time-proven benefits for the
surgical patient. Liabilities associated with benzodiaz-
epines include the potential for paradoxical reactions
including disinhibition, hallucination, and hypoma-
nia. There are also a number of pharmacodynamic
drug interactions including additive interactions and
accentuation of clinical effects of other CNS depres-
sants and antihypertensive agents. Pharmacokinetic
drug interactions with benzodiazepines are protean.
The clinical threshold for respiratory depression is
reduced with the use of benzodiazepines alone or in
combination with other sedatives, which could prove
hazardous in the patient with anatomic airway ob-
struction due to cervicofacial infection. Flumazenil is
a benzodiazepine reversal agent that produces clinical
effects by competitive binding at benzodiazepine
binding sites. Reversal of sedation, respiratory depres-
sion, and other clinical effects of benzodiazepines are
possible with flumazenil. Elderly patients and those
with chronic obstructive pulmonary disease should
receive benzodiazepines with extreme precaution.
The opioids provide sedation, analgesia, and sup-
pression of cough and other upper airway reflexes.
These agents are used for preinduction sedation, but
the practice of using opioids for this purpose in pa-
tients with upper airway obstruction or for awake
fiberoptic airway instrumentation must be ap-
proached with caution, given the potential for respi-
ratory depression. The opioids produce their major
clinical effects via interaction with the opioid recep-
tors ␮, ␬, and ␴. Analgesia, respiratory depression,
and euphoria result from opioid interaction with ␮
receptors. Sedation results from opioid interaction
with ␬ receptors in the reticular activating system and
cerebral cortices. Interaction with these receptors in
the Edinger-Westphal nucleus produces miosis. The
utility of these agents is supplanted by multiple liabil-
ities in patients with upper airway obstruction. Opi-
oid administration may result in histamine release
leading to bronchoconstriction and upper airway ob-
struction in patients with reactive airway disease and
chronic obstructive pulmonary disease. These potent
agents are associated with central respiratory depres-
sion, which may be accentuated by other CNS depres-
sant agents. Potent, short-acting opioids such as
alfentanil and remifentanil are used for airway instru-
mentation in awake intubation of difficult airways.
Naloxone is the sole opioid antagonist that exerts its
effects by competitive inhibition of opioid interaction
BOYD AND SUTTER
with opioid receptors. In this manner naloxone may
be used to reverse the respiratory depression and
sedation that are associated with these agents. Liabil-
ities associated with naloxone use may include dys-
rhythmia and pulmonary edema.
Ketamine is a novel agent that exerts clinical effects
by way of interaction with N-methyl-D-aspartate recep-
tors in the CNS. Ketamine has been used alone or in
combination with dexmedetomidine for sedation dur-
ing awake intubation. It has the unique property of
producing sedation and dissociation of thalamocorti-
cal function of perception from the limbic system
functions of emotion and reaction. It is also capable of
producing analgesia and has often been referred to as
neuroleptanalgesic because of it dissociative and an-
algesic properties. Ketamine, unlike benzodiazepines
and opioids, does not have potent CNS or respiratory
depressant properties. Among the liabilities of ket-
amine use is an increase in airway and oral secretions,
which would increase risk in the setting of cervicofa-
cial infections with airway compromise. Patients with
reactive airway disease may also be at increased risk
for airway compromise because of increased airway
secretions. In addition, the dissociative agents are
associated with emergence delirium characterized by
intense visual and auditory hallucination and un-
wanted movement. Ketamine does not have a specific
reversal agent.
Dexmedetomidine (Precedex) received Food and
Drug Administration approval for ICU sedation of
ventilator-dependent patients in 1999.7 This anes-
thetic drug shares physiologic similarities with cloni-
dine. Dexmedetomidine has the unique property of
“cooperative sedation,” which allows patients to bet-
ter work with medical staff to facilitate intubation
after topical anesthesia has been applied to the airway
and the bronchoscope is passed. This agent is a lipo-
philic imidazole derivative that is a highly selective ␣2
adrenergic receptor agonist, which has sedative and
analgesic effects with minimal effects on ventilation.
The ␣2 agonists act at presynaptic ␣2 receptors includ-
ing the locus ceruleus in the brainstem and various
spinal cord sites and, when bound to these sites,
cause reduction in release of norepinephrine. In their
prospective, randomized study using healthy adult
volunteers, Hall et al6 showed impaired recall by the
subjects after infusion of dexmedetomidine. There
have been 3 ␣2 receptor subtypes identified: ␣2A, ␣2B,
and ␣2C. The subtypes produce cellular actions via
signaling through a G protein–mediated intracellular
effector mechanism.8 At low to moderate doses, ac-
tivity at the CNS located ␣2A receptors produces an-
esthesia and analgesia, but activity at the peripheral
vascular ␣2B receptors is limited.7 The dominant car-
diovascular effect is one of sympatholysis mediated by
the centrally located ␣2B receptors, which may result
1611
in hypotension. Several mechanisms are responsible
for this action, one of which is inhibition of neuronal
discharge from the locus ceruleus in the brainstem,
with resulting inhibition of norepinephrine from pre-
synaptic sites. The sympatholytic effect may also be
seen in the heart, with inhibition of response to the
cardioaccelerator nerve and inhibition of tachycardia
and bradycardia may occur via a vagomimetic effect.
At higher doses, dexmedetomidine may cause in-
creased blood pressure via increased peripheral resis-
tance by acting at these ␣2B vascular sites. The ␣2A
receptor subtype apparently couples in an inhibitory
fashion to the L-type calcium channel in the locus
ceruleus. In the peripheral vasculature the ␣2B recep-
tor subtype appears to couple in an excitatory man-
ner to the same effector mechanism.8 The ␣2 agonists
appear to derive anxiolytic effects via interaction with
CNS-located ␣2C receptors.9 The administration of
high doses (10 ␮g/kg per hour) to patients undergo-
ing surgery in the vicinity of the airways has been
shown to maintain ventilatory drive but may cause
obstructive apnea and increased blood pressure via
increased peripheral vascular resistance. It may also
increase pulmonary vascular resistance and bradycar-
dia and reduce cardiac output.7,8,10 In a randomized,
placebo-controlled study of postsurgical ICU patients,
Venn et al11 reported a postextubation 50% reduction
in morphine requirements in patients who received
dexmedetomidine compared and placebo. They
found no statistically significant differences in oxygen
saturation, respiratory rate, or arterial pH between
those receiving dexmedetomidine compared with
placebo. In addition, several authors have reported
attenuation of hemodynamic responses to airway in-
strumentation during intubation with increasing dex-
medetomidine doses.12-14 Dexmedetomidine will po-
tentiate the effects of intravenous and inhaled
anesthetic agents by between 20% and 80%.14
Coadministration of benzodiazepines and short-
acting opioids with dexmedetomidine during air-
way administration should be approached with cau-
tion because of this pharmacodynamic interaction
with the potential for respiratory depression and
hypotensive responses. The dosages of any supple-
mental agents should be reduced accordingly.
Administration of dexmedetomidine consists of a
loading dose of 0.5 to 1 ␮g/kg over a period of 10 to
20 minutes, followed by continuous infusion at a rate of
0.2 to 0.7 ␮g/kg per hour. Rapid administration must be
avoided to prevent reflex bradycardia and hypertension
associated with an initial catecholamine release.3,6
Conscious sedation of intubated, ventilated patients
with the ␣2 agonists in the ICU setting has been
practiced for over a decade. Its use in patients with
difficult airways because of severe cervicofacial infec-
tions has heretofore received little attention in the
1612
oral and maxillofacial surgery literature. The sedation
profile coupled with its amnestic, analgesic, and an-
xiolytic pharmacodynamic properties, without the li-
abilities of respiratory or myocardial depression, gives
dexmedetomidine a distinct advantage over benzodi-
azepines, short-acting opioids, and propofol for seda-
tion during airway instrumentation for fiberoptic en-
dotracheal intubation.
Acknowledgment
The authors acknowledge the assistance and advice of Merle N.
Tandoc, MD, Clinical Assistant Professor, Department of Anesthe-
siology, State University of New York at Buffalo, School of Medicine
and Biomedical Sciences in the preparation of this manuscript.
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