Guidewire-assisted fiberoptic bronchoscope-guided tracheal intubation: A novel airway management in an invasive thyroid malignancy.

Abstract

Sir, Airway management in patients with tracheal stenosis secondary to invasive tumors, especially when they present with signs of airway obstruction, is a challenging task. Though the primary airway management of choice is not well-defined, airway management in invasive thyroid malignancy can be dealt with a wide range of choices.[1] Here we report such a case, managed successfully by awake guide-wire-assisted fiberoptic bronchoscope (FOB)-guided intubation. A 35-year-old female presented with history of progressively increasing swelling in the region of thyroid for the past 20 years. As it was associated with difficulty in breathing on exertion and lying supine for a past few days, she sought medical help. The swelling was hard in consistency with palpable lower border. Contrast-enhanced computed tomography neck examination revealed a 5 × 4 × 5 cm mass in the right thyroid lobe with tracheal invasion resulting in significant luminal compromise of trachea with tracheal shift toward the left side [Figure 1a and b]. Preoperative FOB examination [Figure 1c] showed a fleshy mass, 4 cm below the level of glottis occupying more than 90% cross-sectional area of the trachea. Our preoperative plan was to perform awake FOB-guided nasotracheal intubation with the help of Cook's polytetrafluoroethylene guidewire. On the day of surgery, she was positioned in 75° semi-recumbent position. Oxygen was supplemented through nasal prongs. Intravenous dexmedetomidine was infused to maintain optimal level of sedation. Awake nasal fiberoptic was performed with spray-as-you-go (SAYGO) technique. Beyond 4 cm from the glottis, tracheal invasion by the tumor mass was noted. Cook's guidewire was passed beyond the tracheal mass. This was followed by the railroading of FOB over it. Once the tracheal carina was identified, the preloaded endotracheal tube (ETT) was railroaded across the tracheal narrowing. The position of ETT was confirmed by FOB. Subsequently, general anesthesia was induced. After completion of total thyroidectomy, sleeve resection of trachea and primary anastomosis was done. She was extubated at the end of surgery and postoperative course was uneventful.Figure 1: (a and b) Sagittal and coronal section of CT showing the invasive thyroid malignant lesion; (c) Fibreoptic bronchoscopy showing the extent of tracheal invasionAirway obstruction by a thyroid tumor may result from extrinsic compression or intrinsic obstruction by tracheal invasion. By context- sensitive airway management principle, airway intervention in such cases depends on the degree of tracheal narrowing, available airway equipments, and anesthesiologist's expertise.[2] We had chosen awake FOB-guided intubation as a primary choice as we anticipated difficulty in ventilation, intubation, and front of neck surgical airway intervention. Preservation of spontaneous ventilation is the safest option in any compromised airway situation.[3] Cook's guidewire was used to negotiate into the narrow space between the mass and the tracheal wall. Railroading the ETT preloaded FOB over the Cook's guidewire prevented unintentional injury to the tumor mass thus ensuring atraumatic passage of the ETT. If the guidewire was not in place beyond the mass, simple FOB-guided intubation would increase the chances of airway edema while passing the FOB/ETT and injury to the tumor mass causing torrential bleeding into the trachea. Placement of Cook's guidewire had in fact facilitated the spontaneous ventilation effectively (as FOB would have totally occupied the narrow space through which the patient was breathing). Also, the presence of the guidewire beyond the tumor mass can help the anesthesiologist quickly railroad the ETT over it and secure the airway in the event of accidental bleeding from the mass during airway management. Rigid bronchoscope was kept ready as a rescue plan if there were events of airway collapse and bleeding from the tumor mass. Preserving spontaneous ventilation is the key to airway management in cases where tracheal lumen is narrowed by infiltrating tumor mass. Cook's guidewire can act as a useful and alternative airway adjuvant in facilitating spontaneous ventilation in such scenarios. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.