AbstractObjectiveSpontaneous ventilation under intravenous anesthesia allows the surgeon to work without interruption or obstruction of the operating field during suspension microlaryngoscopy (SML). High‐flow nasal oxygen therapy (HFNO) is increasingly used in anesthesia. We hypothesized that its use during SML would increase patient safety even in situations where the airway is compromised by tumor or stenosis.Study DesignRetrospective observational study.SettingUniversity Hospital of Lausanne, Switzerland.MethodsAdults patients who were scheduled for elective microlaryngeal surgery and managed with HFNO in spontaneous ventilation under general anesthesia between October 2020 and December 2021.ResultsTwenty‐seven patients for a total of 32 surgical procedures were performed under HFNO with spontaneous ventilation. Seventy‐five percent of the patients had respiratory symptoms. Twelve patients (42.9%) were planned for the treatment of subglottic or tracheal stenosis and 5 patients were managed for vocal cord cancer (18.5%). Out of 32 surgeries, 4 cases of saturation < 92% occurred, 3 of them during the decrease of the fraction of inspired oxygen to 30% for the use of the laser. In 3 cases, the patients were intubated to correct the hypoxemia.ConclusionSpontaneous respiration using intravenous anesthesia and high‐flow nasal oxygen is a modern technique that increases patient safety while allowing the surgeon to work without interruption or imputation of the operative field during SML. This approach is particularly promising for the management of airways compromised by tumors or laryngotracheal stenosis.