Background: First-attempt endotracheal intubation is critical for reducing perioperative complications. Bougies and stylets are commonly used adjuncts to facilitate successful intubation, particularly in patients with difficult airways. This study compared the ease of intubation using preloaded bougie, standard bougie, and stylet-guided techniques. Materials and Methods: In this single-center randomized controlled trial, 195 patients with anticipated difficult airways undergoing elective surgery under general anesthesia were randomly assigned to receive intubation through either a preloaded bougie (Group 1), standard bougie (Group 2), or stylet-guided technique (Group 3). The primary outcome was time to successful intubation. Secondary outcomes included number of intubation attempts, need for additional airway maneuvers, hemodynamic responses, and incidence/severity of postoperative sore throat (POST). Categorical data were analyzed using the Chi-square test; P < 0.05 was considered statistically significant. Results: Demographics were comparable across groups. Mean intubation time was significantly lower in Group 1 (21.5 ± 1.1 s) compared with Group 2 (29.4 ± 1.1 s) and Group 3 (25.4 ± 1.2 s) (P < 0.001). There were no significant differences in first-attempt success (P = 0.16) or need for additional maneuvers (P = 0.76). POST incidence and severity were significantly higher in Group 3 at 2-h (P = 0.01) and 4-h (P = 0.04) after surgery. Conclusion: The preloaded bougie technique was superior to both the standard bougie and stylet-guided techniques, offering faster intubation and fewer postoperative complications in patients with difficult airways. Future studies should evaluate preloaded bougie use in emergencies, varying experience levels, standardize cuff pressure, and compare new airway devices. © 2025 Elsevier B.V., All rights reserved.