Anaesthetic management of a patient with huge Goiter: A case report

S. Nirmal Kumar

Consultant Anaesthesiologist, Kauvery hospital, Cantonment, Trichy

Background

Enlarged long standing thyroid swellings often leads to, Pressure effects – airway obstruction, dyspnoea, dysphagia, vocal palsy. It also cause altered anatomy-lower airway retrosternal extension i.e., SVC obstruction. Thereby making intubation and extubation a challenge to anaesthesiologist. This article is going to discuss a case of long standing papillary carcinoma of thyroid with tracheal narrowing posted for total thyroidectomy.

Case presentation

A 50-year-old male presented with exceptionally large multinodular thyroid swelling for the past 8years. Initially started as a small swelling then gradually progressed to a current size of 12 cm by 21 cm.

He also had change of voice, difficulty in breathing for the past 3 months.

On Examination

The neck swelling had multiple nodules with no distended veins and the swelling did not move with deglutition.

On Palpation, it was firm, immobile, and the skin above was free.

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Airway examination

Mouth opening – 3 Finger breath

Mallampatti score – class 3

Restricted neck movements

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Other Examination

  • IDL – normal vocal cord mobility
  • Blood investigations were WNL
  • Free T3, T4, TSH level- normal limits.

CT neck result

Extent

Superiorly – Thyroid cartilage

Inferiorly – Superior mediastinum

Posterior – Prevertebral space

Laterally – Extensive compression of B/L IJV with compression of trachea.

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Initial Findings

  1. 3D Reconstruction Airway.
  2. Narrowing was 4cm below vocal cord
  3. Narrowest diameter is 3.5mm
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Airway Considerations

1 Huge Goiter

  • Induction – Airway collapse.
  • Plan -Awake Fibreoptic guided intubation

2 Narrowing of trachea

  • Place tube above narrowing
  • Narrowing was 4cm below vocal cord

3 Slit opening 3.5mm diameter

  • Smaller size tube-4mm OD MLS
  • What if we fail?

Back up plans

  1. Rigid Bronchoscope
  2. Jet ventilator
  3. Tracheostomy

Discussion

Goitre is slightly mobile and not hard-Can negotiate the tube beyond narrowing and Flexible Intubation Scope guided ETT placement.

Plan of Anaesthesia

  1. Flexible Intubation Scope guided ETT placement.
  2. Then 4 ml of 4% lignocaine nebulisation was administered for 15 minutes
  3. I.V Fentanyl 50 mcg and midazolam 1mg I.V was given
  4. After 2 minutes of adequate topicalisation and airway was achieved and airway was secured, 7 size ETT was introduced into the trachea by railroading along fiberscope and positioned above the carina under the guidance of FOB.

Surgical procedure

  1. Surgery was done and specimen was removed, Surgery was performed over a period of 10 hours. No major loss/transfusion
  2. Post-procedure, patient was not extubated in view of prolonged surgery and suspicion of tracheomalacia,
  3. Hence patient was electively ventilated in ICU for 6 hours
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Anticipated Complications

  1. Vocal Cord paresis/palsy
  2. Tracheomalacia
  3. Hypocalcemia
  4. Pulmonologist alerted

Bronchoscope guided Extubation

  1. Prepared for extubation
  2. Vocal cord mobility assessed with check laryngoscopy.
  3. ‘Leak test’ was demonstrated around tracheal tube after deflation, so it was considered safe to extubate the patient
  4. Extubated over Flexible scope.

Conclusion

Proper planning and discussing the problems with the patient and surgeons are important for safe outcome. Multidisciplinary planning and with Great Team Effort, we successfully ensured patient safety preoperatively.

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Dr. S. Nirmal Kumar

Consultant Anaesthesiologist

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