To the Editor, The following describes novel airway management in a 60-yr-old female patient with inspiratory stridor, orthopnea, and dyspnea from critical tracheal stenosis. On examination, a 6 9 9 cm neck swelling extended between the cricoid cartilage and the suprasternal notch. The patient’s neck movements were normal, her mouth opening was 4 cm, and the Mallampati score was 3. Nasopharyngoscopy showed a normal glottic opening and mobile vocal cords. Computed tomography showed a large thyroid mass invading the trachea, extending beyond the suprasternal notch, and causing the trachea to deviate to the left. The intratracheal portion of the mass beginning below the cricoid cartilage extended to the first four annular cartilages, obstructing approximately 80% of the lumen so that the widest diameter in this region was 5 mm. Ultrasonography revealed a 4 9 6 cm right thyroid lobe infiltrating the trachea. The thyroid extended beyond the suprasternal notch, which precluded tracheostomy or suprasternal needle tracheotomy. In preparation for surgery, multidisciplinary discussions with the family were conducted, emphasizing the possibility of acute airway compromise following induction of anesthesia. Awake fibreoptic intubation was offered as the best option, but unfortunately the patient refused. A stepwise plan was formulated with the initial plan constituting induction of general anesthesia with fibreoptic bronchoscopy (FOB) facilitated using the GlideScope (Verathon Inc., Bothell, WA, USA). Backup plans were devised involving the King Vision video laryngoscope (King Systems, Indianapolis, IN, USA), an Eschmann tracheal tube introducer (Smiths-Medical International Ltd, Hythe, Kent, UK) (bougie), a tube exchanger, and an intubating laryngeal mask airway device (intubating LMA or ILMA), as needed. A cardiothoracic surgeon, rigid bronchoscopy, and cardiopulmonary bypass were on standby as rescue modalities. No sedative premedication was given. After applying routine monitors and with the patient in a semi-sitting position, anesthesia was induced using a target-controlled infusion of remifentanil in conjunction with 8% sevoflurane in oxygen delivered by mask ventilation. Laryngoscopy was performed using a GlideScope where a Mallampati grade 2 view was observed. A 4.5-mm flexometallic endotracheal tube (ETT) loaded on a 3.6-mm FOB was introduced to the right of the blade. Despite satisfactory visualization, it was difficult to direct the tube through the subglottic area into the trachea. The FOB was maneuvered toward the remaining patent area in the left posterior side of the subglottic area, but this abutted against the infiltrating subglottic mass, causing bleeding. The FOB and ETT were then withdrawn and bag-mask ventilation resumed. We then swapped the GlideScope for a King Vision video laryngoscope. Intubation was then successful using M. R. El-Tahan, MD (&) A. M. Khidr, MD M. AbdulShafi, MD M. S. Othman, MSc Anaesthesia and Surgical ICU, King Fahd Hospital of the University of Dammam, Al Khubar, Saudi Arabia e-mail: mohamedrefaateltahan@yahoo.com