Background <p>Tracheal agenesis is an exceptionally rare and typically lethal congenital airway anomaly presenting with failed intubation. We report a case of unrecognized tracheal agenesis in which supraglottic airway-assisted ventilation enabled concurrent fiberoptic endoscopic evaluation during neonatal resuscitation.</p> Case presentation <p>A preterm male neonate born at 31 weeks and 1&#xa0;day of gestation with polyhydramnios and suspected duodenal atresia developed severe respiratory failure immediately after delivery. Repeated attempts at tracheal intubation were unsuccessful despite vocal cord–like structures being seen. Placement of a size 0.5 supraglottic airway (Air-Q^®) resulted in transient partial ventilation with intermittent colorimetric carbon dioxide detection, permitting fiberoptic endoscopic evaluation. Endoscopy demonstrated a blind-ending subglottic pouch and a distal tracheoesophageal fistula, strongly suggesting tracheal agenesis; computed tomography subsequently confirmed the diagnosis of Floyd type II tracheal agenesis.</p> Conclusions <p>Early supraglottic airway-assisted endoscopic evaluation may facilitate rapid recognition of tracheal agenesis during neonatal resuscitation and support timely, multidisciplinary decision-making after failed intubation.</p>