Background. The need to compromise between surgical
and anesthetic access in airway surgery is an important
clinical problem. We wanted to determine the feasibility
of performing upper airway surgery under awake anesthesia
and spontaneous respiration.
Methods. This was a prospective, clinical feasibility
study. Patients with upper tracheal stenosis were managed
through cervical epidural anesthesia and conscious
sedation, and atomized local anesthetic. No intraoperative
intubation or jet ventilation was required. Outcome
measures were ease of surgery, observer-rated functional
result, early (less than 30 days) complications, and patient-
reported satisfaction.
Results. Twenty consecutive patients with idiopathic
(n
4) or postintubation (n
16) complete (n
3) or
severe (>80%, n
17) subglottic (n
12) or upper trachea
(n
8) stenosis were enrolled. Operations included 12
subglottic and 8 segmental resections with primary anastomosis.
Permissive hypercapnia was well tolerated. Median
length of resection was 4.5 cm (range, 2 to 6 cm), and
12 releases (8 thyrohyoid, 4 suprahyoid) were required.
One patient required a nasotracheal tube for 36 hours. All
but 1 were able to cough and talk immediately, and to
swallow fluids and solids, and were fully mobilized at 6
hours. There were no early complications. Median hospitalization
was 3.1 days (range, 2 to 15). Patients had
excellent (n
16) or good (n
4) functional (n
20)
outcomes, with no early relapse of stenosis. Median
self-reported satisfaction at median 12 months was 9.5 
1.0 (scale, 0 to 10). All patients indicated that they would
be happy to repeat the procedure.
Conclusions. Awake and tubeless upper airway surgery
is feasible and safe, and has a high level of patient
satisfaction. If supported by randomized controlled trial,
this method will change the way airway stenosis surgery
is approached by both surgeons and anesthesiologist.

WE present two cases of the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) during resection of obstructing tracheal papillomata. Conventional anesthesia techniques may be unsafe with near obstructing papillomatous disease of the trachea. The advantage of ECMO in this circumstance is that gas exchange can be totally supported for the duration of the procedure while at the same time providing an apneic unobstructed surgical field. There are reports of the use of ECMO during surgery for tracheal obstruction and resection in neonates and children but to our knowledge this is the first account of its use in adults.