Airway Challenge Research Articles

Anesthetic management of a patient with mandibular hypoplasia, deafness, progeroid features, lipodystrophy syndrome: a case report

BackgroundMandibular hypoplasia, deafness, progeroid features, and lipodystrophy (MDPL) syndrome is a rare autosomal dominant disorder that presents unique challenges for anesthetic management due to its multisystemic manifestations. This report outlines the anesthetic considerations for MDPL patients based on our case experience.Case presentationA 15-year-old male with MDPL syndrome underwent testicular extraction under general anesthesia. Insertion of a peripheral venous catheter was challenging due to scleroderma-like skin. Although the facial features of MDPL syndrome suggested a difficult airway, intubation with a McGrath™ Mac video laryngoscope was successful. Despite MDPL syndrome’s association with hypertriglyceridemia due to lipodystrophy, this patient’s triglyceride levels were normal. Thiamylal and sevoflurane were used without issues such as delayed emergence from anesthesia.ConclusionsMDPL syndrome requires careful preoperative assessment and tailored anesthetic management due to potential airway challenges arising from its distinctive facial features and the possibility of altered anesthetic pharmacokinetics associated with lipodystrophy.

Rates of tracheostomy in patients with complex skeletal dysplasia: A 32-year institutional experience

ObjectiveRespiratory failure secondary to multilevel airway compromise may present complex airway challenges in patients with specific skeletal dysplasia diagnoses. This study sought to identify and characterize subgroups of skeletal dysplasia diagnoses that more frequently undergo operative airway evaluations and tracheostomy placement. MethodsRetrospective electronic medical record review of pediatric patients with an ICD-10 associated skeletal dysplasia diagnosis and CPT-specified airway intervention at a tertiary pediatric hospital from 1990 to 2022. Patients without a defined skeletal dysplasia diagnosis, subjects with craniosynostosis syndromes, and those with limited clinical data were excluded. Collected variables included demographics, age at diagnosis, comorbidities, operative procedures, and airway interventions. Descriptive statistical analysis was utilized to evaluate data distribution. ResultsFrom the initial population of 313 patients, 41 subjects were confirmed to have clinical features and/or genetic testing consistent with a skeletal dysplasia diagnosis. A tracheostomy was placed in 19/41 subjects and these patients’ records were further analyzed. Skeletal dysplasia groups with more frequent tracheostomy placement included Filamins and related disorders, Sulfation disorders, and Chondrodysplasia punctata. In the patients with a tracheostomy, skeletal dysplasia was diagnosed at a median age of 0.3 years (IQR 4.8 years), and tracheostomy was initiated at a median age of 1.8 years (IQR 2.2 years). Only four of these patients were successfully decannulated, and two subjects are deceased. ConclusionOver 32 years, nearly half of the skeletal dysplasia patients who underwent airway interventions eventually had a tracheostomy placed. Respiratory insufficiency and complex airway management challenges are common manifestations of skeletal dysplasia.

Evaluation of Yukmijihwang-Tang as a Novel Preventive Agent in Ovalbumin-Induced Murine Asthma

Yukmijihwang-tang (YJT) is a blend of six herbal ingredients that has long been used in Asia for various diseases, including diabetes mellitus and mental decline. Here, we assessed the prophylactic efficacy of YJT in a murine model of asthma induced by ovalbumin (OVA). Male C57BL/6 mice underwent sensitization followed by an airway challenge with OVA for 1 h. YJT (100 or 300 mg/kg once daily) was administered orally for 6 days. Our analyses revealed that YJT significantly reduced inflammatory cell counts in bronchoalveolar lavage fluid (BALF), decreased the concentrations of interleukin (IL)-4, IL-5, and IL-13 in BALF, and lowered the relative mRNA levels of thymic stromal lymphopoietin (TSLP) and tumor necrosis factor α (TNFα) in lung tissues. Histological analyses showed that YJT substantially decreased inflammation and mucus hypersecretion in the bronchial airway. YJT also effectively reduced oxidative stress, as evidenced by improved levels of malondialdehyde (MDA), total glutathione, glutathione reductase (GR), and reduced glutathione (GSH). YJT also markedly suppressed the phosphorylation of nuclear factor-kappa B (NF-κB) in lung tissues. Together, these results show that YJT effectively inhibits respiratory inflammation, mucus hypersecretion, and oxidative stress induced by OVA, suggesting its potential for asthma treatment.

GLUT1 mediates bronchial epithelial E-cadherin disruption in TDI-induced steroid-insensitive asthma

Objective Down-regulation of bronchial epithelial E-cadherin is an important of feature of severe asthma, including steroid-insensitive asthma. Yet, the mechanisms involved in E-cadherin disruption are not fully understood. This study was aimed to investigate the role of glucose transporter 1 (GLUT1) in dysregulation of E-cadherin in toluene diisocyanate (TDI)-induced steroid-insensitive asthma. Methods A murine model of steroid-insensitive asthma was established by TDI sensitization and aerosol inhalation. Selective GLUT1 antagonists WZB117 and BAY876 were given to BALB/c mice after airway challenge. In vitro, primary human bronchial epithelial cells (HBECs) cultured in an airway-liquid interface (ALI) were exposed to TDI. Results TDI exposure markedly up-regulated GLUT1 in murine lungs and HBECs. Pharmacological inhibition of GLUT1 with BAY876 decreased airway hyperresponsiveness, neutrophil and eosinophil accumulation, as well as type 2 inflammation in vivo. Besides, the TDI-induced down-regulated expression of full-length E-cadherin was also partly recovered, accompanied by inhibited secretion of soluble E-cadherin (sE-cadherin). WZB117 also exhibited mild therapeutic effects, though not significant. In vitro, treatment with GLUT1 inhibitor relieved the TDI-induced disruption of E-cadherin in HBECs. Conclusions Taken together, our data demonstrated that GLUT1 modulates bronchial epithelial E-cadherin dysfunction production in TDI-induced steroid-insensitive asthma.

Preventive effects of prenatal administration of OM-85/BV on asthma and respiratory infection risk in the offspring: A review of animal models.

Asthma is the most common chronic disease in childhood affecting the daily lives of many patients despite current treatment regimens. Therefore, the need for new therapeutic approaches is evident, where a primary prevention strategy is the ultimate goal. Studies of children born to mothers in farming environments have shown a lower risk of respiratory infections and asthma development. Already at birth, these newborns have demonstrated accelerated maturation and upregulation of host defense immune functions suggesting a prenatal transplacental training of the innate immune system through maternal microbial exposure. This mechanism could possibly be utilized to help prevent both respiratory infections and asthma in young children. Human studies exploring the potential preventative effects of pregnancy bacterial lysate treatment on asthma and respiratory infections are lacking, however, this has been studied in experimental studies using mice through administrations of the bacterial lysate OM-85. This review will present the current literature on the immunomodulatory effects relevant for respiratory infections and asthma in the offspring of mice treated with OM-85 throughout pregnancy. Further, the review will discuss the cellular and molecular mechanisms behind these effects. In conclusion, we found promising results of an accelerated immune competence and improved resistance to airway challenges as a result of prenatal bacterial lysate treatment that may pave the way for implementing this in human trials to prevent asthma and respiratory infections.

Endothelin-1-mediated Brainstem Glial Activation Produces Asthmatic Airway Vagal Hypertonia Via Enhanced ATP-P2X4 Receptor Signaling in Sprague-Dawley Rats.

The occurrence of major asthma symptoms is largely attributed to airway vagal hypertonia, of which the central mechanisms remain unclear. This study tests the hypotheses that endothelin-1-mediated brainstem glial activation produces asthmatic airway vagal hypertonia via enhanced action of adenosine 5'-triphosphate on neuronal purinergic P2X4 receptors. A rat model of asthma was prepared using ovalbumin. Airway vagal tone was evaluated by the recurrent laryngeal discharge and plethysmographic measurement of pulmonary function. The changes in the brainstem were examined using ELISA, Western blot, luciferin-luciferase, quantitative reverse transcription-polymerase chain reaction, enzyme activity assay and immunofluorescent staining, respectively. The results showed that in the medulla of rats, endothelin receptor type B and P2X4 receptors were primarily expressed in astrocytes and neurons, respectively, and both of which, along with endothelin-1 content, were significantly increased after ovalbumin sensitization. Ovalbumin sensitization significantly increased recurrent laryngeal discharge, which was blocked by acute intracisternal injection of P2X4 receptor antagonist 5-BDBD, knockdown of brainstem P2X4 receptors, and chronic intraperitoneal injection of endothelin receptor type B antagonist BQ788, respectively. Ovalbumin sensitization activated microglia and astrocytes and significantly decreased ecto-5'-nucleotidase activity in the medulla, and all of which, together with the increase of medullary P2X4 receptor expression and decrease of pulmonary function, were reversed by chronic BQ788 treatment. These results demonstrated that in rats, allergic airway challenge activates both microglia and astrocytes in the medulla via enhanced endothelin-1/endothelin receptor type B signaling, which subsequently causes airway vagal hypertonia via augmented adenosine 5'-triphosphate/P2X4 receptor signaling in central neurons of airway vagal reflex.

Bacterial antigens and asthma: a comparative study of common respiratory pathogenic bacteria

Objective: In a previous study we have shown that, in the presence of interleukin (IL)-33, repeated, per-nasal challenge of murine airways with Streptococcus pneumoniae (S. pneumoniae) organisms induces human asthma-like airways inflammation. It is not clear, however, whether this effect is unique or manifest in response to other common respiratory pathogens.Methods: To explore this, airways of BALB/c mice were repeatedly challenged per-nasally with formaldehyde-inactivated bacterial bodies in the presence or absence of murine recombinant IL-33. Serum concentrations of S.pneumoniae, Moraxella catarrhalis (M.catarrhalis) and Haemophilus influenzae (H.influenzae) lysates-specific IgE were measured in patients with asthma and control subjects.Results: We showed that in the presence of IL-33, repeated, per-nasal airways exposure to the bodies of these bacteria induced airways hyperresponsiveness (AHR) in the experimental mice. This was accompanied by cellular infiltration into bronchoalveolar lavage fluid (BALF), eosinophilic infiltration and mucous hypertrophy of the lung tissue, with elevated local expression of some type 2 cytokines and elevated, specific IgG and IgE in the serum. The precise characteristics of the inflammation evoked by exposure to each bacterial species were distinguishable.Conclusions: These results suggest that in the certain circumstances, inhaled or commensal bacterial body antigens of both Gram-positive (S. pneumoniae) and Gram-negative (M. catarrhalis and H. influenzae) respiratory tract bacteria may initiate type 2 inflammation typical of asthma in the airways. In addition, we demonstrated that human asthmatic patients manifest elevated serum concentrations of M.catarrhalis- and H.influenzae-specific IgE.

BECC438b TLR4 agonist supports unique immune response profiles from nasal and muscular DTaP pertussis vaccines in murine challenge models.

The protection afforded by acellular pertussis vaccines wanes over time, and there is a need to develop improved vaccine formulations. Options to improve the vaccines involve the utilization of different adjuvants and administration via different routes. While intramuscular (IM) vaccination provides a robust systemic immune response, intranasal (IN) vaccination theoretically induces a localized immune response within the nasal cavity. In the case of a Bordetella pertussis infection, IN vaccination results in an immune response that is similar to natural infection, which provides the longest duration of protection. Current acellular formulations utilize an alum adjuvant, and antibody levels wane over time. To overcome the current limitations with the acellular vaccine, we incorporated a novel TLR4 agonist, BECC438b, into both IM and IN acellular formulations to determine its ability to protect against infection in a murine airway challenge model. Following immunization and challenge, we observed that DTaP + BECC438b reduced bacterial burden within the lung and trachea for both administration routes when compared with mock-vaccinated and challenged (MVC) mice. Interestingly, IN administration of DTaP + BECC438b induced a Th1-polarized immune response, while IM vaccination polarized toward a Th2 immune response. RNA sequencing analysis of the lung demonstrated that DTaP + BECC438b activates biological pathways similar to natural infection. Additionally, IN administration of DTaP + BECC438b activated the expression of genes involved in a multitude of pathways associated with the immune system. Overall, these data suggest that BECC438b adjuvant and the IN vaccination route can impact efficacy and responses of pertussis vaccines in pre-clinical mouse models.

Modified cadaver technique to simulate contaminated airway scenarios to train medical providers in suction-assisted laryngoscopy and airway decontamination.

Simulation training plays a vital role in modern medical education, fostering safe skill development. Task-trainer manikin and cadaveric airway management training (CAMT) offer realistic airway management practice. Simulation allows learners the opportunity to manage high-risk, low-frequency scenarios, including difficult airways and massive airway contamination, common in emergent airway management. The suction-assisted laryngoscopy and airway decontamination (SALAD) technique was developed to address massive airway contamination. This paper describes two methods to simulate massive airway contamination utilizing cadavers. We detail our techniques for both esophageal and nasopharyngeal delivery of simulated airway contaminant. Nasopharyngeal delivery was less invasive and required less time to set up. Utilizing cadavers to simulate massive airway contamination in CAMT provides learners with tools to manage airway complications effectively, enhancing readiness for complex airway challenges while promoting patient safety in clinical practice.

Airway Challenges in a Child with Treacher Collins Syndrome having Ventricular Septal Defect, Oculofacial Malformations and Oesophageal Atresia: A Case Report

Treacher Collins Syndrome (TCS), also known as Franceschetti syndrome, is an autosomal dominant condition marked by various developmental anomalies confined to the head and face. It primarily affects craniofacial structures derived from the first and second branchial arches. Patients usually present with down-slanting palpebral fissures, mandibular hypoplasia, lower eyelid colobomas, external ear malformations, and hearing loss. Congenital heart defects and cryptorchidism are two other unusual anomalies. It is typically a bilateral condition. The symptoms and physical features of TCS can vary greatly from person to person. Some individuals may be affected so mildly that their condition goes undiagnosed, whereas others may develop serious, lifethreatening complications. Individuals with TCS may require specialised airway management due to a narrow mouth aperture and micrognathia. They are best served by an interprofessional team that can coordinate all aspects of their care. Timely detection and management can improve the quality of life for these patients. The present case report presents the airway challenges in an eightyear-old child with TCS who has congenital malformations and presented with swallowing difficulty, which was later diagnosed as oesophageal atresia.

Anaesthesia and Airway Challenges in Patients with Corrosive Pharyngo-oesophageal Stricture: Experience of a Tertiary Care Centre

Background: Ingestion of corrosive substances causes necrosis of the tissues of the upper airway and upper gastrointestinal tract resulting not only in acute airway injuries but also long-term sequelae like strictures. Medical and surgical management of these strictures has been discussed extensively; however, there is little literature available on the anaesthetic management of pharyngo-oesophageal strictures. We hereby discuss our experience in managing these patients undergoing surgical correction. Methods: Out of a total of 57 cases of corrosive ingestion injuries between 2008 and 2016, medical records of 15 patients with complex pharyngeal or high oesophageal strictures undergoing surgical intervention were reviewed. The preoperative findings, the extent of airway involvement and any airway intervention done were noted. Based on the surgical intervention, patients were divided into two groups; Group A included patients undergoing repeated string dilatation and Group B included those undergoing coloplasty. Type of anaesthesia given, details of airway management, intraoperative and postoperative course and complications were noted. Results: Group A consisted of 10 patients who underwent endless string dilatation, and Group B consisted of five patients who underwent coloplasty. In Group A, general anaesthesia with endotracheal intubation was given to all patients except for one patient who was tracheostomised. Two patients had significant glottic narrowing and required a smaller size tube. In Group B, four out of five patients were tracheostomised, while one had a normal glottic opening. General anaesthesia with epidural analgesia was given to all patients. Severe haemodynamic changes were seen during tunnelling through the posterior mediastinum for colonic interposition. All patients were extubated on the table. None of the patients required postoperative ventilatory or inotropic support. Conclusion: Management of corrosive pharyngo-oesophageal strictures is challenging and requires a multidisciplinary approach. Careful assessment and management of the airway, vigilant intraoperative haemodynamic monitoring and good pain management are the key contributions of anaesthesia care.

Anaesthetic Challenges in a Child with Noma (Necrotising Ulcerative Stomatitis) for Abbe Flap Reconstructive Surgery

Noma, also known as necrotising ulcerative stomatitis, gangrenous stomatitis or cancrum oris is an orofacial gangrene. It is usually seen in children of developing countries, between the age group of 2 and 7 years, who are malnourished and debilitated by disease. We present a case of a 7-year-old child posted for Abbe flap reconstruction followed by division. We have discussed the airway challenges in this case and suggest a tailored approach as per the patient’s requirement, the anaesthesiologist’s skills and the equipment available.

Navigating airway challenges in cystic hygroma: I-gel as a vital tool

Navigating airway challenges in cystic hygroma: I-gel as a vital tool

Negative pressure suction test: An intraoperative airway maneuver to assess effectiveness of surgical correction of tracheobronchomalacia.

Surgical correction of tracheobronchomalacia (TBM) has evolved greatly over the past decade, with select pediatric institutions establishing dedicated surgery and anesthesia teams to navigate the complexities and challenges of surgical airway repairs. Although anesthetic techniques have evolved internally over many years to improve patient safety and outcomes, many of these methods remain undescribed in literature. In this article, we describe the intraoperative negative pressure suction test. This simulates the negative pressure seen in awake and spontaneously breathing patients, including the higher pressures seen during coughing which induce airway collapse in patients with TBM. Also known as the Munoz maneuver in surgical literature, this test has been performed on over 300 patients since 2015. The negative pressure suction test allows for controlled intraoperative assessment of surgical airway repairs, replaces the need for risky intraoperative wake-up tests, increases the chances of a successful surgical repair, and improves anesthetic management for emergence and extubation. We provide a guide on how to perform the test and videos demonstrating its efficacy in intraoperative airway evaluation. As surgeries to repair TBM become more prevalent in other pediatric institutions, we believe that pediatric patients and anesthesia providers will benefit from the insights and methods described here.

Awake Nasal Fiberoptic Intubation in Lateral Position for Severely Obese Patients with Anticipated Difficult Airway: A Randomized Controlled Trial.

Obesity is a well-recognized risk factor for difficult intubation. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended. We aimed to investigate the utility of awake nasal fiberoptic intubation in severely obese patients with suspected difficult airway while positioning them in the lateral decubitus position. This randomized controlled trial compared lateral and supine positions for awake nasal fiberoptic intubation in severely obese patients with an anticipated difficult airway by assessing the success rate, time needed to secure the airway, peri-procedural adverse events, and postoperative satisfaction of patients. Sixty patients with a median age of 37 [inter-quartile range (IQR): 29-44] years were included, of which 47 (78.3%) were females. The median body mass index (BMI) was 45.5 [IQR: 42.5-50.8] kg/m2. The success rate of fiberoptic intubation was 100% in both groups. The time needed to successfully secure the airway was 188 [148.8-228.8] seconds (s) in the lateral position, compared to 214.5 [181.8-280.5] s in supine position (p = 0.019). Intraprocedural cough was more common in the supine position group (n = 8; 26.7%), compared to the lateral position group (n = 3; 10%; p = 0.095). Postoperative sore throat was more common in the lateral position group (n = 12; 40%) compared to the supine position (n = 5; 16.7%; p = 0.045). In conclusion, Intubation in the lateral position is a promising technique that is equivalent to the routine supine position during fiberoptic intubation. In fact, intubation in the lateral position took less time to successfully secure the airway.

C-MAC VL as Saviour Following Failed Intubation Attempts in an Infant with Huge Hydrocephalous

Airway management in infants can become more challenging in the presence of congenital anomalies such as hydrocephalus. In this case, we present the extreme airway challenges faced during the intubation of a 7-month-old child with massive hydrocephalus presenting for ventriculoperitoneal (VP) shunt surgery. The C-MAC video laryngoscope (VL) turned out to be the ultimate saviour after the failure of direct laryngoscopy and Airtraq. Paediatric airway management can sometimes be a nightmare for the anaesthesiologist in such scenarios. Early use of rescue devices such as the C-MAC VL can help tide over the crisis.

The Impact of Airway Obstruction on Feno Values in Asthma Patients

Exhaled nitric oxide (Feno) is used as a marker of type-2 airway inflammation in asthma management. Studies with airway challenges demonstrated that a reduction in airway caliber decreases Feno levels. To evaluate the impact of airway caliber reduction occurring spontaneously in patients with asthma on Feno values in daily clinical practice. In this post hoc analysis, Feno, FEV1, and asthma control questionnaire scores were recorded on each visit for 120 (1073 visits) adult patients with asthma. Blood eosinophils were measured intermittently. The intraindividual relationship between Feno and FEV1 was evaluated via a linear mixed model. The determinants of the individual mean Feno were measured by a stepwise multivariate linear model including individual mean FEV1, inhaled corticosteroid dose, asthma control questionnaire score, and blood eosinophils. Variations in the negative Feno-FEV1 relationship within individuals at different times were significantly determined by the individual's mean FEV1. This relationship did not hold for individuals above the 75th and below the 25th quartiles. The best explanatory variables for individual mean Feno were FEV1 (+4.3 parts per billion/10%pred) and blood eosinophil count (+1 part per billion per 100 cells/mm3). In the presence of variable degrees of heterogeneous patterns of airway inflammation, airway caliber is shown to be an independent and significant determinant of Feno when measured in patients with asthma. We would propose a+4-parts-per-billion correction factor to the measured Feno value for each 10% reduction below 100% predicted FEV1. Doing this should improve the rigor of interpretation of Feno as an indicator of type-2 inflammation in patients with low FEV1.

Clinical characteristics and follow-up analysis of 12 patients of acute phosphine poisoning

Objective: To investigate the clinical characteristics of patients with acute phosphine poisoning, and to follow up and evaluate the prognosis of patients. Methods: In May 2022, 12 patients with phosphine poisoning by respiratory inhalation in Beijing Chao-Yang Hospital of Capital Medical University were analyzed. The patients were treated with symptomatic support therapy. Three months later, patients were re-evaluated the symptoms of poisoning, pulmonary function and magnetic resonance imaging (MRI) of the brain to understand the prognosis of the phosphine poisoning. Results: The main symptoms of 12 patients were respiratory and central nervous system symptoms with hypoxia. The symptoms of poisoning improved after treatment. Follow-up found that the patients had different degrees of residual symptoms. Pulmonary function showed increased airway resistance. Airway challenge test was positive in some patients. MRI of the head of some patients showed small ischemic focus in bilateral frontal lobes. Conclusion: Acute phosphine poisoning may cause persistent damage to the respiratory system and central system, and residual symptoms after 3 months.

Ultrastructural analysis of the intracellular surfactant in lungs of healthy and ovalbumin sensitized and challenged Brown Norway rats

Introduction: In human and experimentally induced asthma, a dysfunction of the intra-alveolar-surface active agent (surfactant) has been demonstrated. Type II alveolar epithelial cells (AEII) synthesize, secrete and recycle surfactant. Prior to secretion, intracellular surfactant is stored in specific secretory organelles of AEII. The lamellar bodies (Lb) represent its ultrastructural correlate. The aim of this study was to investigate whether disturbances of the intra-alveolar surfactant are accompanied by alterations in the intracellular surfactant.Material and Methods: Brown-Norway rats were sensitized twice with ovalbumin (OVA) and heat killed Bordetella pertussis bacilli. During airway challenge, an aerosol of 5% ovalbumin/saline solution (0.25 l/min) was nebulized. 24 h after airway challenge, lungs were fixed by vascular perfusion. AEII and their Lb were characterized stereologically by light and electron microscopy.Results: In both groups, AEII were structurally intact. The number of AEII per lung and their number-weighted mean volume did not differ (controls: 49 × 106, 393 µm3; asthmatics: 44 × 106, 390 µm3). A mean of 90 Lb in AEII of asthmatics and of 93 Lb in AEII of controls were evaluated. The Lb mean total volume was 59 µm in asthmatics and 68 µm in controls. Values of both parameters did not reach significance. Also, the size distribution and mean volume of Lb was not influenced by asthma induction, because the volume weighted mean volume of Lb (2.18 µm in asthmatics compared to 1.87 µm in controls) and the numerical weighted mean volume (0.96 µm in asthmatics and 0.75 µm in controls) were comparable in both groups.Conclusion: The obtained results suggest that asthma-induced surfactant dysfunction is not related to disturbances in the intracellular surfactant´s ultrastructural correlates.

Mediastinal goitre - a South African case series.

Mediastinal goitres are rare and may be diagnosed late since they are likely to manifest with non-specific cardiorespiratory symptoms especially when there is no visible cervical component. The imaging modality of choice is a contrast-enhanced computed tomography (CT) scan of the neck and chest after incidental finding of goitre on chest X-ray indicated for a condition unrelated to goitre. This case series aims to highlight the peculiarity of mediastinal goitre in terms of clinical presentation, surgical approach, airway challenges at anaesthesia, specific complications and final histopathological report. Over a nine-year period, four cases of euthyroid mediastinal goitre underwent sternotomy. The mean age was 57.5 years (45-71) and all patients were female. Most patients presented with non-specific cardiorespiratory symptoms. The difficult airway set was used in all cases and there were two instances of damage to the recurrent laryngeal nerve (RLN). All histopathological reports were benign. The presentation of the mediastinal goitres was atypical. Cervical incision and sternotomy were performed in all cases. There were two instances of RLN injury and no malignant histopathology. Despite the potential threat to the airway, all intubations were uneventful.