Introduction

During elective surgeries, an unanticipated difficult airway is one of the most significant challenges and a potentially catastrophic event in anesthetic practice. In spite of systematic preoperative assessment using standardized tools such as the Mallampati classification, thyromental distance, interincisor gap, neck mobility, and the Look externally, Evaluate the 3-3-2 rule, Mallampati classification, Obstruction, Neck mobility mnemonic, a significant proportion of airway complications remain unidentified without performing laryngoscopy [1]. The Difficult Airway Society (DAS) 2025 guidelines recommend a linear algorithm progressing through plans (A-D), with focus on continuous oxygenation and early escalation as cardinal principles [2]. Moreover, the 2022 American Society of Anesthesiologists Practice Guidelines also stress team-based responses and proactive planning [3]. However, anatomical differences, which are undetectable on external examination, particularly the subglottic tracheal narrowing, may result in transforming a predicted straightforward intubation into a life-threatening emergency.

Subglottic stenosis, postintubation, inflammatory or idiopathic, is a well-known cause of unexpected intubation difficulty. In their case report, Hibino et al. described asymptomatic subglottic stenosis discovered during anesthetic induction in a 74-year-old woman scheduled for elective orthopedic surgery in whom subglottic resistance was encountered despite entirely normal preoperative assessment [4]. Importantly, unrecognized subglottic stenosis may manifest only with asthma-like symptoms or with unexplained dyspnea, and the cross-sectional area of the trachea must be reduced by over 50% before audible stridor becomes apparent [5]. In asthmatic patients, such symptoms are directly attributed to bronchospasm rather than mechanical obstruction, further increasing the chances of missed diagnosis.

The patient's past anesthetic history is a resource that is often overlooked for obtaining preoperative airway information. Postoperative sore throat is considered to be a minor, self-limiting postoperative complication, occurring in as many as 32.4% of patients after endotracheal intubation [6]. Nevertheless, if postoperative sore throat is severe or occurs for an extended duration (beyond the usual two to six hours after extubation), it could be a sign of previous subglottic problems. This case illustrates that careful attention to previous anesthetic symptoms may provide the single most actionable preoperative predictor of difficult airway in patients with no other apparent risk factors.