AIRWAY MANAGEMENT IN A PATIENT WITH HUGE THYROID

Airway management of a patient with a huge thyroid swelling is a real challenge to the anaesthetist. The anaesthetic concerns and  the  management of airway are discussed here.

60 year old female patient is admitted to the A&E department with history of neck swelling and stridor. She is a known case of medullary carcinoma thyroid with lymph node metastases.

The patient assumed a sitting position as stridor exacerbated on lying supine and looks distressed .She was oriented conscious and responding to comm ands.  Examination of the chest revealed b/l basal creps and oxygen saturation was 88% with oxygen mask. ABG showed resp acidosis with hypoxemia.The pulse rate was regular and ECG was normal.The thyroid swelling was huge and completely occupying the anterior neck with the trachea not at all palpable at any point and with evidence of possible retrosternal extension.Oxygen by mask administered and patient postioned sitting, leaned forward.

Investigations done:

• Routine hemogram
• CXR showed severe narrowing and deviation of the trachea to the right side, by compression from the mass

• CT scan showed narrowed tracheal orifice(the black round hole) with compression of the esophagus and nodular metastases

Additional investigations (may be deferred here as this patient requires emergency airway access)

• Pulmonary function tests may show a restrictive defect with high FEV1/FVC ratio
• Carotid angiogram to assess the vessels

Anaesthetic problems anticipated

1) Induction or any anaesthetic intervention should be done with the patient in sitting position, as supine position further compromises airway.

2)Emergency tracheostomy, minintracheostomy or retrograde tracheostomy cannot be
performed here due to tumour extension.

3)Distorted airway anatomy makes intubation impossible even with fiber optic bronchoscopy.

4)Ventilation through Fastrach may not be adequate and may not be effective due to tracheal compression, if intubation through Fastrach fails.

5)Airway blocks like trans tracheal or superior laryngeal nerve blocks cannot be performed.

6) Tracheostomy malfunction may occur post operatively due to  tracheal collapse because of  tracheomalacia.


The  ideal management in this case would be a fiberoptic trial of intubation through the nasal or oral route, in the sitting position with topical airway anaesthesia, followed by palliative debulking of the tumor and then tracheostomy.

• Lignocaine jelly or gargle may be used to anaesthetise the posterior tongue
• Glossopharyngeal nerve block can be performed intra orally by injecting local anaesthetic into the base of the palatoglossal fold.
• Nasal passages may be anaesthetised by lignocaine jelly using swabs or catheter.
• Excellent anaesthesia of the larynx and trachea can be achieved with topical aerosolised lignocaine.
• Intravenous sedation can be given with midazolam or fentanyl in titrated doses during the procedure, if patient is uncomfortable.
• A smaler sized re inforced tube is preferred for intubation

The other suggested techniques are awake intubation through a fastrach,intubation
following rigid fiber optic bronchoscopy and inhalation induction using sevoflurane in the sitting postition followed either by blind intubation or fiberoptic aided intubation.



Anaesthetist should be vigilant, careful and well prepared while dealing with neck masses compromising airway. Management should done in operation theatre set up with all available equipments ready to tackle the difficult situation. The ENT and General surgeon also should be available to deal with emergency.

Thanx to Dr.Santhosh Kumar Sathiarajan, Radiologist,  Ibri hospital, Muscat.

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