Nasal intubation should be avoided in patients with suspected basal skull fractures (e.g., tympanic cavity hemorrhage, otorrhea, petechiae on the mastoid process known as Battle’s sign, or petechiae around the eyes known as panda sign) or severe facial fractures. Because approximately 10% of highspeed motor vehicle accident head injury patients have associated cervical spine injuries, it is prudent to assume that all head injury patients have coexisting cervical spine injury until proved otherwise. Additionally, the patient described in this question may have abnormal airway anatomy because of extreme micrognathia, facial injuries, and obesity. Taken together, direct laryngoscopy with rapid-sequence induction is probably not anacceptable technique for securing this patient’s airway because intubation and mask ventilation cannot be guaranteed due to his anatomy and need for inline stabilization of the neck. In contrast, awake intubation by direct, video, or fiberoptic laryngoscopy or performance of tracheostomy is considered an appropriate technique for tracheal intubation of this patient. Mask and laryngeal mask airway (LMA) techniques may provide a patent airway but do not ensure protection of the airway against aspiration of gastric contents