Discussion

This case underscores three important and interrelated points. First, airway symptoms prior to intubation are an underutilized tool for assessing the airway; second, systematic stepwise management can be used when the larynx meets subglottic resistance; third, complete reversal of the neuromuscular block after intubation, plus awake extubation, is important in patients with documented difficult airways.

Sore throat is a common postendotracheal intubation problem. In a study published in 2026, Moulder et al. conducted a systematic review across 43 studies (with more than 21,000 enrolled patients) that found a pooled incidence of postoperative sore throat of 32.4% [6]. Usually, most cases represent transient mucosal irritation caused by cuff pressure or by the movement of the tube; however, symptoms of unusual severity or duration, as in the history of this patient, warrant a more deliberate interpretation. Subglottic contact injury during forced intubation against a structurally narrow trachea would be expected to produce precisely this symptom profile. Similarly, Hibino et al. described an analogous presentation in a 74-year-old female patient in whom asymptomatic subglottic stenosis was discovered only upon encountering subglottic resistance during induction with no history of identifiable warning signs [4]. Together, these reports call for a more inquisitive history of previous anesthetic (with a special focus on symptoms of subglottic difficulty).

The airway management in this case was based on the architecture of the DAS 2025 guidelines [2] that still follow the four-plan (A-D) linear algorithm but with renewed emphasis on maximizing first-attempt success, using capnography at each attempt to confirm successful airway management, and early team activation. The use of video laryngoscopy as the primary laryngoscopic tool is consistent with empirical evidence; a meta-analysis by Araujo et al. confirmed superior first-attempt intubation success with video laryngoscopy over direct laryngoscopy in anatomically challenging patients [7]. The use of video laryngoscopy, in combination with a bougie, is specifically supported by Barnicle et al., who suggest a bougie’s use as a primary adjunct rather than a rescue maneuver in patients, with a 60% improvement in first-attempt success in patients with Cormack-Lehane Grade III or IV airways [8]. In this particular case, bougie placement confirmed the trachea, and tube failure was due to subglottic, not supraglottic, obstruction.

The senior anesthetist's use of the rotational technique is anatomically based. When left oriented, the endotracheal tube is in its natural shape and is at its highest cross-sectional profile at the subglottic area of resistance. Bevels rotate clockwise to anticlockwise, which gradually changes the bevel orientation and allows the tube to be advanced. This technique is described in the literature on bougie-in-channel video laryngoscopy [9] and follows the concept of counterclockwise rotation to prevent arytenoid impingement when railroading. However, rotating the tube does not reduce the diameter of the shaft; it only changes the angle at which the bevel meets the resistance, which may explain why rotation helped the tube pass. Escalation is a logical, least traumatic maneuver to include in the anesthetist's armamentarium and should be considered first on the list when subglottic resistance is confirmed.

Sugammadex use for reversal is due to the lack of proportionality between the risk of residual neuromuscular blockade and its use for reversal in patients with known difficult airways. Postextubation obstruction may occur as a result of incomplete reversal of pharyngeal tone and reduced hypoxic ventilatory drive, especially in those with underlying respiratory disease, for example, asthma [10]. In patients with tracheobronchial stenosis, Lu et al. showed significantly shorter time to extubation and postanesthesia care unit discharge, along with lower incidence and duration of hypotension, with sugammadex vs. neostigmine in a retrospective cohort of patients undergoing rigid bronchoscopy [10].