Background: One challenge associated with awake fiberoptic intubation is providing adequate sedation with sufficient airway topicalization while maintaining the patient's cooperation.

Objectives: This study aimed to assess intubation condition during awake fiberoptic intubation (AFOI) using dexmedetomidine alone, compare it when combined with different methods of airway topicalization.

Methods: We included 56 patients who were undergoing elective surgery under general anesthesia in a prospective double-blind controlled clinical trial distributed into 4 equal groups (n=14 in each); Group C (Sedation / Control) received only dexmedetomidine as a sedative for AFOI , Group N (Nebulization group): received dexmedetomidine + lidocaine 2% nebulization, Group A (Atomization): received dexmedetomidine + lidocaine 2% by atomization “modified McKenzie technique", Group S (SAYGo): received dexmedetomidine + lidocaine 2% by “Spray As You Go" technique. Achievement of good patients' intubation condition which was assessed by (Five‐point fiberoptic intubation comfort score, three-point behavior score, and intubation time) were the primary outcome.

Results: The 5-point fiberoptic intubation comfort score and 3-point behavior score were significantly better in atomization and SAYGo groups (p=0.011 and 0.002 respectively). Intubation time was statistically significantly shorter in Atomization group (1.85 mins) than SAYGo group (2.3 mins) followed by nebulization group (3.3 mins), while the sedation group recorded the longest intubation time (5.6 mins).

Conclusion: Airway topicalization along with sedation using dexmedetomidine provides better intubation condition, hemodynamic stability, and patient satisfaction compared to sedation alone among patients undergone awake fiberoptic nasotracheal intubation for elective surgeries under general anesthesia. However, atomization and spray-as-you-go techniques are superior to nebulization.