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During complex maxillofacial surgeries, there may arise a need for change of endotracheal tube (ETT) route from transnasal position to transoral position to improve surgical visibility. It is usually a planned procedure, under controlled conditions with clear airway. It can be accomplished by removing the nasotracheal tube and replacing it with an orotracheal tube using intubat ing devices after completion of transoral resection. This could be challenging if the skull base is exposed, oral cavity is filled with blood and with the presence of an open maxilla in a patient who is on a rigid pinion fixation. There is a high risk of losing the airway, aspiration of oral contents, central nervous system infection, etc. A 30-year-old male patient presented with a history of double vision and headache for 3 months with otherwise normal neurological examination. His magnetic resonance imaging revealed a large well-defined lobulated extra-axial mass lesion in the sphenoid clival region measuring 6.7 cm × 4.8 cm × 3.0 cm, extending into the sphenoid sinus. Midfacial approach with Le fort 2 incision was planned ►Fig. 1. Nasal intubation was requested by the maxillofacial surgeon; hence, the ►Fig. 2 patient was intubated nasally with a 7.5 mm internal diameter (ID) cuffed flexometallic ETT. After the resection of maxilla, neurosurgeon opined that the approach through the midfacial plane alone woul d yield suboptimal resection of a tumor, while transnasal transsphenoidal

Unanticipated Intraoperative Endotracheal Tube Switch during Skull Base Surgery