Unanticipated difficult airway due to friable tongue-base lesions: the decisive role of situational awareness and human-factor leadership

Unanticipated difficult airways associated with friable supraglottic pathology may deteriorate rapidly after induction. A 35-year-old male with a normal preoperative airway assessment was scheduled for elective endoscopic retrograde cholangiopancreatography (ERCP) under general anesthesia when direct laryngoscopy unexpectedly revealed bulky, friable tongue-base lesions causing immediate bleeding and a Cormack–Lehane grade 3b view. Videolaryngoscopy provided only transient visualization before progressive hemorrhage and edema obscured the glottis despite suction. After two unsuccessful attempts, worsening bleeding and declining visualization indicated airway deterioration. Although current guidelines would have permitted an additional attempt by another experienced anesthesiologist, further instrumentation was deliberately declined. Based on situational awareness and anticipation of loss of oxygenation, the decision was made to abort intubation and awaken the patient, and this plan was clearly communicated to the operating room team. Neuromuscular blockade was reversed with sugammadex. The patient recovered without hypoxemia or respiratory compromise, reporting transient odynophagia and hoarseness. Postoperative nasofibroscopy confirmed friable papilliform-like lesions at the tongue base, validating the decision to avoid further attempts. This case highlights that airway expertise depends not only on technical skill but also on escalation control, leadership, and non-technical competencies that prevent progression toward a cannot intubate, cannot oxygenate scenario.