PURPOSE: To present a case of unintentional tracheal extubation in a prone positioned patient with a known difficult airway. CLINICAL FEATURES: This case report describes the unintended tracheal extubation of an achondroplastic dwarf with kyphosis undergoing spinal fusion and instrumentation. The patient had a history of obstructive sleep apnea and a difficult airway requiring fibreoptic-guided tracheal intubation through an air-Q supraglottic airway device. Abrupt head movement during a wake-up test to evaluate lost motor-evoked potential signals resulted in dislodgement of the tracheal tube. Airway obstruction was evidenced by rapid oxygen desaturation and the absence of end-tidal capnography waveforms despite apparent chest excursions. An air-Q was used for successfully rescuing the airway and quickly re-establishing oxygenation and ventilation, which eliminated the need for emergent supine positioning for airway management. The air-Q was then used as a conduit for fibreoptic-guided tracheal intubation while the patient remained in the prone position. CONCLUSION: This case highlights some of the safety advantages of supraglottic airway devices for airway rescue and subsequent tracheal intubation even with the patient in the prone position. The use of an air-Q may have the advantages of not requiring an intubation introducer technique and allowing for direct tracheal intubation with an appropriately sized cuffed tracheal tube.