Airway management of a difficult airway due to prolonged enlarged goiter using loco-sedative technique
A 67-year-old, 58 kg woman presented with complaints of gradually increasing swelling in front of neck for past 20 years. Patient had history of palpitation and anxiety 7 years before and was diagnosed to be hypertensive and hyperthyroid. She was put on tablets neomercazole 10 mg BD, verapamil 40 mg OD, olmesartan 40 mg OD, which she was continuing. She had no history of change in voice and no respiratory symptoms. She was diagnosed a case of multinodular goiter (MNG), advised surgery, and was admitted for the same in June 2007. Surgery was deferred as patient couldn't be intubated despite 5-6 attempts. Patient then defaulted and re-appeared in December 2010 with complain of recent difficulty in swallowing for 1 month. On examination, patient was conscious, co-operative. Pulse was 90/min and blood pressure 140/90 mmHg. ECG showed sinus rhythm. She had no stridor and no respiratory difficulty, even on lying down. The neck swelling was 30 cm × 15 cm × 10 cm in size, nodular, extending from lower jaw to below sternal notch []. The lower limit of the swelling was neither visualized nor palpable. There were no distended veins on chest.\nThe swelling did not move with deglutition. On palpation, it was firm, immobile, and the skin above it was free. Airway examination showed less than 2 fingers mouth opening due to a large thyroid mass obstructing mouth opening, protruding incisors; Mallampati score couldn't be determined due to restricted mouth opening, limited neck extension, and severely restricted neck flexion.\nIndirect laryngoscopy revealed normal vocal cord mobility. Radiological examination revealed lateral displacement of the trachea to the right on antero-posterior view and no compression of trachea in lateral view []. CT scan showed huge MNG with retrosternal extension []. Free T3, T4, and TSH levels were in normal limits.\nIn view of previous history, anticipated difficult mask ventilation due to huge size of the tumor and difficult laryngoscopy and intubation, fiberoptic intubation was planned for the patient under loco-sedative technique. Difficult airway management cart with rigid bronchoscope and jet ventilation was kept ready. A team of cardiothoracic surgeons and perfusionist were informed and were asked to be at stand by for a femoro-femoral cardiopulmonary bypass in the event of inability to maintain airway or a cardiovascular event. The procedure was explained to the patient, and written consent was taken. Patient was kept fasting for 6 hours for solids and 2 hours for water before OT. Anti-thyroid medication and anti-hypertensive were continued till morning of surgery. Ranitidine 50 mg was given with a small sip of water on night before and morning of surgery. No preoperative sedation was prescribed. The patient shifted to the OT. Standard monitors (ECG, pulse oximeter, and NIBP) were attached, and the baseline vitals were recorded. Inj. glycopyrrolate 0.2 mg i.v. was administered. Xylometazoline was instilled in both the nostrils for vasoconstriction of nasal passage to facilitate passage of fiberoptic bronchoscope (FOB) without mucosal injury. The patient's airway was anesthetized by application of lignocaine 2% jelly in the nostrils, lignocaine viscous 2% gargles, 4 ml of lignocaine 4% nebulization, and lignocaine spray (10%). Oxygen was administered via oxymask at a rate of 5 L/min. Patient was administered 2 mg midazolam and 60 mcg fentanyl i.v. to allay anxiety and for mild sedation. FOB was loaded with a 6.0 mm armored endotracheal tube. After explaining to the patient, the bronchoscope was inserted through one of the nostrils and advanced towards laryngeal inlet. Laryngeal and esophageal openings were visualized side-by-side with the laryngeal inlet on the right side. Patient was instructed to take deep breaths to facilitate identification of the airway. FOB could be negotiated through the vocal cords with difficulty because of airway distortion. The fiberscope was advanced and positioned above the carina. Lignocaine 2.0% was administered via the drug port of the FOB, as and when required, to facilitate passage of FOB. Endotracheal (ET) tube was then threaded over the FOB, and the FOB removed. Eighty mg propofol was administered prior to railroading the ET tube through the vocal cord to attenuate the laryngeal and tracheal reflex. The breathing circuit was attached, and the tube placement was confirmed by movement of reservoir bag and capnography []. Sevoflurane inhalation was started. 150 mcg of fentanyl and 5 mg vecuronium were administered intravenously. The ET was firmly secured, and anesthesia was maintained with O2 in N2O and sevoflurane, vecuronium, and fentanyl. Total 400 mg lignocaine was given to the patient.\nTotal thyroidectomy with cervical extraction of retrosternal goiter was performed. The patient remained hemodynamically stable throughout the procedure. Post-procedure, patient was not extubated in view of probable tracheomalacia. On postoperative day 2, after patient was maintaining blood gases on “T – piece trial,” tracheal tube cuff was deflated and leak test was performed. Leak was demonstrated around tracheal tube after deflation, so it was considered safe to extubate the patient. A trolley for emergency intubation with rigid bronchoscope was kept ready. Patient was extubated and kept in post-operative area for 24 hours before being discharged to ward [].