In patients with severe upper airway narrowing because of radiation fibrosis, an awake fibreoptic intubation may be impossible and a tracheotomy is the only means of securing this airway; however, there may be no evident warning signs that the airway lumen is too narrow.

Diagnostic imaging with CT scanning or MRI may detect these patients with severely narrowed airways without clinical symptoms.

Awake fibreoptic intubation is accepted as the gold standard for intubation of patients with an anticipated difficult airway.

Radiation fibrosis may cause difficulties during the intubation procedure. We present an unusual severe case of radiation induced changes to the larynx, with limited clinical symptoms, that caused failure of the fibreoptic intubation technique.

A review of the known literature on radiation fibrosis and airway management is presented.

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