DOI: https://doi.org/10.36347/sjmcr.2026.v14i04.008

Pages: 622-627

Aims and Background: Unexpected difficult intubation caused by subglottic stenosis is a rare but potentially life-threatening event during general anesthesia, as it may rapidly lead to hypoxia and perioperative morbidity. Subglottic stenosis can remain clinically silent and may not be detected during routine preoperative airway assessment. Case Description: We report two cases of unanticipated difficult airway management due to previously undiagnosed, asymptomatic subglottic stenosis caused by granulation tissue. The first case involved a 72-year-old man scheduled for right total hip arthroplasty who experienced unexpected resistance during tracheal intubation with a 7.0-mm internal diameter (ID) tube despite an adequate glottic view. Fiberoptic evaluation revealed subglottic granulation tissue, and successful intubation was achieved via a 6.0-mm ID tube. The second case involved a 74-year-old woman undergoing left mastoidectomy and tympanoplasty, in whom multiple intubation attempts using 6.0–7.0-mm ID tubes and laryngeal mask airway ventilation failed due to subglottic narrowing. Definitive airway management was accomplished with a 5.5-mm ID tube using a stylet. In both cases, subglottic stenosis was not suspected on the basis of the preoperative clinical evaluation. Conclusion: Asymptomatic subglottic stenosis caused by granulation tissue may present as unexpected difficult intubations. Anesthesiologists should maintain a high index of suspicion in patients with a history of tracheostomy or repeated endotracheal intubations, even in the absence of respiratory symptoms. The immediate availability of advanced airway equipment, including video laryngoscopes and fiberoptic bronchoscopes, is essential to ensure patient safety.