Orbital fistula tract - a case report of a rare cause of impossible facemask ventilation

BACKGROUND: Adequate facemask ventilation during induction of anaesthesia is a key aspect of patient safety. Difficulties can therefore be life-threatening for the patient. CASE PRESENTATION: The case presented here illustrates a rare cause of an orbital fistula that led to a serious problem during facemask ventilation and demonstrates why team communication is so important. CONCLUSIONS: Preparatory errors in patient assessment and anaesthetic preparation were identified as sources of error.