Airway management of huge thyroid swelling having tracheal deviation: Challenges faced

Abstract

Airway management in huge goiters present with challenges among anesthesiologists worldwide. Usually thyroid swelling presents with retrosternal extension, tracheal compression poses certain airway challenges. In our case there was no retrosternal extension or tracheal compression but tracheal deviation was present which make airway management difficult.55yr old male pt, weight 60 kg, moderately built, came with chief complaints of gradually increasing swelling in front of neck since 3 years. He was k/c/o systemic hypertension on regular treatment taking tab. amlodipine 5mg OD. He was having no change in voice, no other systemic illness. He was evaluated for left sided huge goitre having neck swelling of size 14 cm × 15 cm × 10 cm. The mass was extending from lower jaw to below sternal notch, get below the swelling was possible. Xray neck AP and lateral view revealed tracheal deviation to right by the mass, this patient was posted for the hemithyroidectomy considering difficult airway plan of anaesthesia was awake fibreoptic intubation (under topical anaesthesia and sedation). In this case because of tracheal deviation to right the glottic structures were distorted, view to vocal cords was obscured by left arytenoid making the airway management difficult.In general the difficulty of tracheal intubation in cases with thyroid disease is affected by compression or deviation of the trachea, the position and hardness of the tumour. Generally recommended techniques for securing airway in such patients are 1. Awake fiberoptic intubation 2. Awake direct laryngoscopy aided intubation 3. Inhalational induction. Awake fibreoptic intubation using local anaesthesia - sedation technique is a suitable option in selected group of patients having possibility of airway obstruction.