Background <p>Post-thyroidectomy airway complications, though rare, can be life-threatening. We present a case of acute airway compromise due to a combined tracheal fistula and critical stenosis in a patient with a history of giant goiter, successfully managed through multidisciplinary collaboration and awake fiberoptic intubation.</p> Case presentation <p>A 70-year-old female with a 20-year history of giant goiter underwent total thyroidectomy. On postoperative day 3, she developed neck erythema, swelling, and dyspnea. Emergency cervical computed tomography (CT) revealed a tracheal fistula and severe tracheal stenosis at the C7 level, with a minimal diameter of 4.6&#xa0;mm. A multidisciplinary team decided to attempt awake fiberoptic intubation under topical anesthesia, with immediate tracheostomy as a backup plan. Due to severe stenosis and tissue edema, intubation was challenging. Under conscious sedation and topical anesthesia, a 6.0# endotracheal tube was successfully placed using flexible bronchoscopy. Subsequent surgical debridement and tracheal repair were performed under general anesthesia. Notably, dynamic bronchoscopy revealed that the inspiratory phase airway patency was better than suggested by the static CT interpretation, which had indicated the 4.6&#xa0;mm stenosis.</p> Conclusions <p>This case highlights that acute airway obstruction after thyroidectomy requires prompt multidisciplinary management. It underscores a critical clinical insight: radiographic findings, often based on expiratory phases, may overestimate the degree of dynamic airway collapse. A comprehensive assessment combining symptoms, physical signs, imaging, and especially dynamic bronchoscopic evaluation is essential for accurate diagnosis and safe airway management planning.</p>