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difficulty under direct laryngoscopy using a traditional laryngoscope with a size 3 Macintosh blade. After securing the airway orally, we attempted nasotracheal intubation with 5.0- and 5.5-mm ID tubes. However, rhinostenosis prevented passage of the nasotracheal tubes bilaterally. To prevent infective endocarditis, flomoxef sodium 1 g was administered intravenously before the surgery. General anesthesia was maintained with sevoflurane 1.5% with oxygen and remifentanil 0.1–0.15 μg/kg/min. To reduce aortic and pulmonary valve regurgitation, his heart rate was kept