We Need to Stay Flexible: Making a Case for Fiberoptic Intubation Skills

Advances in video laryngoscopy (VL) have revolutionized airway management with higher successful first-attempt intubation rates as compared to direct laryngoscopy. However, in select patients with complex airway anatomy, particularly those with head and neck cancer, awake fiberoptic intubation (AFOI) remains the gold standard. The growing preference for VL risks marginalizing AFOI, potentially disadvantaging patients who cannot be safely intubated otherwise. We present the case of a 61-year-old male with a history of advanced throat cancer and prior extensive head and neck surgery, who presented with rectal bleeding and was diagnosed with sigmoid cancer requiring urgent colectomy. Preoperative airway assessment revealed multiple predictors of a difficult airway, including recurrent pharyngeal tumor extending into the larynx, subglottic stenosis, limited neck mobility, and distorted anatomy. In a prospective multidisciplinary team approach, AFOI was successfully performed using flexible fiberoptic bronchoscopy under anxiolysis and topical anesthesia, with emergency front-of-neck access on standby. The airway was secured uneventfully as planned. The patient was extubated at the end of surgery without complication and discharged from the ICU on postoperative day 2. This case underscores the critical importance of preserving fiberoptic intubation skills for managing difficult airways. VL is not always feasible in anatomically altered or surgically reconstructed airways. Despite its decreasing frequency in clinical use, fiberoptic intubation remains a valuable, potentially lifesaving, technique. Simulation and team-based approaches are essential for skill retention and preparedness. In an era dominated by VL, AFOI must remain a core competency for anesthesiologists managing complex airways. Continued training, simulation, and clinical application are vital to prevent the extinction of this critical skill.