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Occipital meningomyeloceles are rare and challenging conditions for the anaesthesiologist, mainly because of the difficulty in securing the airway, the need for special positioning, and the constant risk of rupturing the sac during handling. We report two paediatric cases, a neonate and an infant, both presenting with large occipital meningoencephaloceles requiring individualised airway strategies driven by extreme lesion size and anatomical constraints. In each case, airway access was achieved using modified positioning techniques such as lateral positioning and the head-dangling method to avoid pressure on the swelling. Anaesthetic management was directed at maintaining body temperature, ensuring fluid balance and keeping the circulation stable throughout surgery. Both children underwent successful excision of the lesion and recovered well without neurological complications. These cases highlight the importance of thoughtful preparation, adaptable airway strategies and close teamwork between surgeons and anaesthesiologists in improving outcomes for children born with such complex congenital problems.