Airway management has significantly improved, but difficult airways remain a major challenge for anesthetists, causing 25% of anesthesia-related deaths. When a difficult airway is expected, securing the airway while the patient is awake is the safest approach. Fiberoptic bronchoscopy, introduced in 1967, is the gold standard for managing difficult airways, with a success rate of 88%-100%. It allows direct guidance and can be performed while the patient is awake, maintaining oxygenation. Effective airway anesthesia is essential and can be achieved using local anesthetics through various techniques, such as sprays, gargles, and nebulization, or by blocking specific nerves. Nebulization is simple, non-invasive, and effective for awake fiberoptic intubations, though it might need supplementation with nerve blocks or the spray-as-you-go (SAYGO) technique. Dexmedetomidine, an α2 adrenoreceptor agonist, provides sedation without significant respiratory depression and reduces salivary secretions, making it suitable for awake fiberoptic intubation. It has anxiolytic, hypnotic, analgesic, amnesic, and antisialogogue properties. Nebulized dexmedetomidine, combined with lidocaine, has been effective for awake videoendoscopic intubations, reducing coughing and recovery time. This study aims to evaluate the effectiveness of adding dexmedetomidine to lignocaine nebulization for awake fiberoptic nasotracheal intubation in patients with predicted difficult airways, as current literature lacks sufficient evidence-based recommendations.