The following was encountered while intubating a 50 year old male with a history of neck radiation for the treatment of esophageal cancer and resection of his epiglottis and tongue base. The patient was 20 hours NPO and denied any history suggestive of active esophageal pathology.

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We optimized airway positioning with external laryngeal manipulation and placed an endotracheal tube over a gum bougie and continued to the patient’s unrelated orthopedic fixation.