Mechanical airway obstruction secondary to retropharyngeal haematoma is a life-threatening emergency and should be anticipated in all cervical spine injure patients regardless of the severity of trauma. Most retropharyngeal haematomas described in the literature have involved complicating factors such as anticoagulant therapy, tumour, aneurysm, infection or major cervical spine injury. Several authors have however described haematomas causing airway compromise with minor hyperextension injuries. We describe the case of a 19-year-old male who was involved in a motorcycle accident. He sustained an atlanto-occipital fracture-dislocation and a very large retropharyngeal haematoma which resulted in airway obstruction and a subsequent difficult intubation. We outline the normal anatomy of the retropharyngeal space, the pathogenesis of retropharyngeal haematomas, and outline techniques of intubation available.