Managing an Awake Fiberoptic Intubation in Thyroidectomy for a Morbidly Obese Patient with

Massive Submental and Substernal Goiter

Thomas Hurysz, M.D., Claire Mattson M.D., and Zana Borovcanin, M.D., M.Sc., FASA

Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY

INTRODUCTION

Thyroidectomy is the most common endocrine surgery in the world with multinodular goiter

accounting for approximately 12% of thyroid surgeries. The presence of a large goiter poses a

unique challenge to airway management for a variety of reasons:

• Significantly distorted upper airway anatomy can preclude the use of airway devices such as

supraglottic airways and impair visualization of the glottis.

• Goiters with substernal extension may compress and deviate the trachea, making intubation and

potential surgical airway difficult or impossible.

• Loss of pharyngeal and laryngeal tone post-induction can further exacerbate these

challenges, potentially causing complete airway collapse with inability to ventilate or intubate.

• Lastly, performing a surgical airway in a patient with massive goiter poses

significant challenge due to distortion of typical anatomic landmarks and increased bleeding risk.

• The World Health Organization (WHO) grades goiters on visibility with a scale of zero to three,

with grade three representing a goiter that is “very pronounced, with potential difficult breathing”

Consequentially, additional considerations are needed to safely secure the airway in this patient

population.

CASE DESCRIPTION

41 -year-old female presenting for total thyroidectomy for resection of massive goiter.

Medical history notable for morbid obesity (weight 165kg, BMI 68), untreated OSA, and large bilateral

goiter extending superiorly behind the mandible and inferiorly below the sternum. ENT was consulted prior

to case and noted they would not be able to perform a surgical airway on this patient.

IMAGING: Thyroid ultrasound

revealed thyroid lobe sizes 11.3x6x7 cm on

right and 10.7x5x4 cm on left. CT

chest revealed circumferential compression

of the trachea.

PHYSICAL EXAM: Limited neck mobility

secondary to the goiter and a Mallampati

score of IV.

Anesthetic Management: Airway Topicalization

Antisialogogue: 0.2 mg glycopyrrolate IV was given 20 min prior to topicalization to decrease oral

secretions

Nebulized Topicalization: 3 ml of 4% lidocaine was administered by nebulizer in the preoperative area

Glossopharyngeal Nerve

Sedation: 2 mg of midazolam were administered following nebulization with an additional 4mg given in

the operating room over spaced-out intermittent boluses for anxiolysis and amnesia during the

remainder of the topicalization

Topicalization: 5% lidocaine ointment

applied to the base of the tongue

Superior Laryngeal Nerve

Topicalization: pledgets with 4%

lidocaine applied to bilateral tonsillar

pillars

Recurrent Laryngeal Nerve

Topicalization: Williams airway placed

and 3 cc of 4% lidocaine sprayed

through the Williams airway using

laryngo-tracheal atomizer device to

anesthetize vocal cords

Anesthetic Management: Awake Fiberoptic Intubation

• A Bflex2 5.0 glidescope bronchoscope pre-loaded with a 7.0 Nerve Integrity Monitor

(NIM) endotracheal tube was advanced through 100 mm Williams airway

with mild difficulty getting past large tongue.

• Williams airway facilitated immediate visualization of larynx upon passing tongue.

• The FOB was advanced through the vocal cords, and the ETT was successfully guided

into the trachea, encountering resistance that required careful manipulation.

• Placement of ETT was verified via end-tidal CO2 and visualization of tracheal rings and

carina with fiberoptic bronchoscope.

• Oxygenation was maintained via 6L nasal cannula throughout the process of

awake FOI.

• Anesthesia was subsequently induced, and thyroidectomy successfully performed.

• Patient was extubated smoothly following removal of the goiter after spontaneous

breathing confirmed with adequate tidal volumes.

Discussion and Recommendations

Awake fiberoptic intubation is the gold standard for management of predicted difficult

airway. Patient factors such as high BMI, limited mouth opening, higher Mallampati score,

and minimal neck mobility are indicators of a difficult airway, but do not

alone always necessitate awake FOI. The presence of a massive, retrosternal goiter can lead

to airway distortion and tracheal compression as seen on our patient’s CT. Classification

based on anatomy recommends awake fiberoptic intubation for any type 3 goiter, defined as

a substernal goiter with significant intrathoracic mass as induction prior to

securing the airway could lead to a life-threatening “cannot ventilate, cannot oxygenate”

scenario. Additionally, emergency surgical airway can be impossible or pose significant

bleeding risk and challenge due to distorted anatomy and body habitus. Given these factors,

awake FOI was the safest choice for this patient. Additionally pre-procedurally adequate

airway topicalization along with patient education and cooperation can increase rates of

successful intubation, reduce adverse events, and improve the patient experience.