Conclusions

This case highlights that a history of prolonged or severe cough and sore throat following a previous general anesthetic should not be dismissed as a routine, self-limiting postintubation symptom. Although no anesthetic records were available in this case, the severity and duration of the reported symptoms raise the possibility that the prior anesthetic may have involved a difficult or traumatic intubation. Such a history may represent an early clinical clue to an evolving difficult airway, and its significance may only become apparent at a subsequent anesthetic, as in this case. We propose that a detailed airway history, specifically enquiring about the nature and duration of postextubation symptoms from previous anesthetics, should form part of routine preoperative assessment, with a low threshold for nasendoscopy or airway ultrasonography where such a history is present. In our patient, definitive endoscopic or radiological evaluation was not pursued postoperatively given the absence of ongoing symptoms and the immediate resolution of the airway difficulty; however, this recommendation is intended to guide future preoperative assessment in similar patients.

In this case, unanticipated subglottic resistance was successfully managed with video laryngoscopy, a reduced-size endotracheal tube, early senior involvement, and a bidirectional rotational technique with gentle axial pressure. This approach should not be generalized as a standard strategy; management of unexplained resistance during intubation must be individualized according to adequacy of oxygenation, quality of laryngeal view, and the suspected level and mechanism of the resistance encountered.