To the Editor: Halo traction for stabilization of the cervical spine limits access to the face and immobilizes the neck, making tracheal intubation difficult. Fiberoptic and Bullard laryngoscopes, intubating laryngeal mask airway, and Combitube have been used for airway management in such cases (1–4). We describe retrograde tracheal intubation in a patient with halo traction. A 42-year-old woman sustained scalp avulsion and C2 spine fracture when her hair was caught in a thresher. A halo device was applied to stabilize the cervical spine in mild flexion (Fig. 1). We did not have access to a fiberoptic laryngoscope, which limited our options. We elected to perform awake retrograde intubation.Figure 1.: Radiograph (lateral view) of the cervical spine showing the C2 fracture and the halo device in situ.After explaining the procedure to the patient, we administered topical anesthesia to the airway, and then introduced an 18-guage IV cannula into the trachea through the cricotracheal membrane. We then threaded a ureteral stent as a guidewire from the cricotracheal membrane into the mouth. We were unable to thread a 7.0 mm endotracheal tube over the guidewire, as it could not navigate past the glottis. We advanced the guidewire into the nasopharynx, and brought it out through the nose. We could easily advance the endotracheal tube through the nose and into the trachea. Figure 2 explains why the nasal route was successful, when the oral route failed. During oral intubation, the guidewire traversed the anterior part of the glottis and formed an acute curve, accentuated by the flexed neck. This curve caused the tube to impinge on the anterior glottis. The nasal guidewire forms a wider curve and passes through the wider posterior glottis, resulting in successful intubation (Fig. 2).Figure 2.: (a) The oral guidewire lies in the anterior part of the glottis and forms an acute curve; (b) The nasal guidewire lies in the posterior glottis and forms a wide curve.Retrograde intubation can be performed through either the cricothyroid or the cricotracheal membrane. The cricotracheal approach is more likely to be successful because the guidewire makes a wider curve at the laryngeal inlet. It also avoids other complications of the cricothyroid approach, such as hematoma, hoarseness, and subcutaneous emphysema (5). Neerja Bhardwaj, MD Sandhya Yaddanapudi, MD Department of Anaesthesia and Intensive Care Surinder Makkar, MCh Department of Plastic Surgery Postgraduate Institute of Medical Education and Research Chandigarh, India [email protected]