Page | 86

Vol. 7, Issue 1, January-March 2013 Saudi Journal of Anaesthesia

Airway management of a difficult airway due to prolonged enlarged goiter using loco-sedative technique

Divya Srivastava, Sanjay DhiraajDepartment of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

A B S T R A C T

Appropriate airway management is an essential part of anesthesiologist’s role. Huge goiters can lead to distorted airway and difficulty in endotracheal intubation. In this report, we present a case of a 67‑year‑old woman with a huge toxic multinodular thyroid swelling, gradually increasing in size for last 20 years, where trachea was successfully intubated. She had a history of deferred surgery in June 2007 due to inability to intubate, despite 5‑6 attempts using different laryngoscopes, bougie, and stylet. Patient was re‑admitted in December 2011 for the surgery and was successfully intubated this time with help of fiberoptic intubation using loco‑sedative technique. Patient was electively kept intubated postoperatively in view of chances of tracheomalacia due to prolonged large goiter. She was extubated successfully on post‑op day 2 after demonstration of leak around trachea following tracheal tube cuff deflation. The different techniques of managing the difficult airway in these patients are discussed.

Key words: Difficult airway, fiberoptic intubation, huge thyroid

Address for correspondence: Dr. Divya Srivastava, Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh, India. E-mail: dr.divshri@gmail.com

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 complainof recentdifficultyinswallowingfor1month.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 swellingwas30 cm × 15 cm × 10 cm in size, nodular, extending from lower jaw to below sternal notch [Figure 1]. The lower limit of the swelling was neither visualized nor palpable. There were no distended veins on chest.

The swelling did not move with deglutition. On palpation, itwas firm, immobile, and the skin above itwas free.Airway examination showed less than 2 fingersmouthopening 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,andseverelyrestrictedneckflexion.

INTRODUCTION

Enlarged thyroid gland can lead to compromised airway with difficulty in tracheal intubation. Amathieu et al. reportedthattheoverallincidenceof difficultintubationinthyroidsurgerywas11.1%.[1] Fiberoptic intubation (FOI) has been reported successfully in patients with enlarged thyroidsinadifficultairwaysituation.[2,3] We present one suchcaseof successfulintubationwithhelpof fiberopticbronchoscope (FOB) using loco-sedative technique in a female patient with huge goiter, where previous surgery was deferred because of inability to intubate.

CASE REPORT

A 67-year-old, 58 kg woman presented with complaints of gradually increasing swelling in front of neck for past

Access this article onlineQuick Response Code:

Website:

www.saudija.org

DOI:

10.4103/1658-354X.109829

C A S E R E P O R T

[Downloaded free from http://www.saudija.org on Tuesday, September 17, 2013, IP: 41.128.165.40]  ||  Click here to download free Android application for this journal

Page | 87Srivastava and Dhiraaj: Airway management in a patient with prolonged enlarged goiter using loco-sedative technique

Saudi Journal of Anaesthesia Vol. 7, Issue 1, January-March 2013

Indirect 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 [Figure 2]. CT scan showed huge MNG with retrosternal extension [Figure 3]. Free T3, T4, and TSH levels were in normal limits.

In viewof previous history, anticipated difficultmaskventilation due to huge size of the tumor anddifficultlaryngoscopy and intubation, fiberoptic intubationwasplanned for the patient under loco-sedative technique. Difficultairwaymanagementcartwithrigidbronchoscopeand 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 applicationof lignocaine2%jellyinthenostrils,lignocaineviscous2%gargles,4mlof lignocaine4%nebulization,andlignocainespray(10%).Oxygenwasadministeredviaoxymask 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. FOBcouldbenegotiatedthroughthevocalcordswithdifficultybecauseof airwaydistortion.Thefiberscopewasadvancedand positioned above the carina. Lignocaine 2.0%wasadministered 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 circuitwasattached,andthetubeplacementwasconfirmedbymovement of reservoir bag and capnography [Figure 4a]. Sevofluraneinhalationwasstarted.150mcgof fentanyland5 mg vecuronium were administered intravenously. The ET wasfirmlysecured,andanesthesiawasmaintainedwithO2

Figure 1: Pre-operative photograph of the patient

Figure 3: CT scan showing distortion of the larynx by goiterFigure 4: a) Patient after intubation b) photograph of the patient after surgery and extubation

a b

Figure  2: X-ray showing tracheal compression in A-P but not in lateral view

[Downloaded free from http://www.saudija.org on Tuesday, September 17, 2013, IP: 41.128.165.40]  ||  Click here to download free Android application for this journal

Page | 88Srivastava and Dhiraaj: Airway management in a patient with prolonged enlarged goiter using loco-sedative technique

Vol. 7, Issue 1, January-March 2013 Saudi Journal of Anaesthesia

in N2Oandsevoflurane,vecuronium,andfentanyl.Total400 mg lignocaine was given to the patient.

Total 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,” trachealtubecuff wasdeflatedandleaktestwasperformed.Leakwasdemonstratedaroundtrachealtubeafterdeflation,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 [Figure 4b].

DISCUSSION

Difficultywithintubationmaybecausedbyanenlargedthyroid gland producing tracheal deviation, compression, or both.[4] Amathieu et al. concluded that classical predictive criteria like mouth opening <35 mm, Mallampati III or IV, limited neck movements <80°, and thyromental distance werereliablepredictorsof difficultairway.[1] Induction of general anesthesia in such cases could be risky because it may precipitate complete airway closure and make mask ventilation and tracheal intubation nearly impossible. Pressure on trachea exerted by a long-standing neck mass could have caused laxity to the parts of tracheal wall, which can lead to complete collapse of the airway with muscle relaxation. FOI, which can safely and promptly secure the airway, has been recommended for the airway management inpatientswithdifficult airways. Inour case, therewashistory of failed intubation with traditional methods, patienthadprominentincisors,restrictedneckflexion,andextension and was Mallampati’s class IV airway.

Malhotra and Sodhi[5] have reported a strategy for airway management of thyroid patients if preoperative assessment has increased concerns regarding the airway. The strategy included the following options: Inhalation induction with sevofluraneinthesemi‑supineorsemi‑sittingposition,awakeFOI, tracheotomy, or ventilation through a rigid bronchoscope. The utility and safety of performing tracheotomy in the awake patient with a large neck mass prior to induction of general anesthesia are debatable, due to the location of the huge mass and the displaced anatomy it produces.[6] Problems like failure to visualize the glottis, trauma, bleeding, and laryngospasm has been reported with FOI.[7] However, compared with inhalation induction, the risk of losing the airway is minimal.[2] Inhalationinductionwithsevofluranewasnotanoptionaspatient may obstruct her airway as she loses consciousness.[5] Also, over-sedation with the agent might lead to respiratory

distress, and a ‘cannot intubate cannot ventilate’ situation might arise. Retrograde passage of an epidural catheter through the cricothyroid membrane and passage of a tracheal tube over the catheter from above,[8] or introduction of a trans-tracheal cannula was also an option[9] but was discarded due to large thyroid mass and indistinct anatomical landmarks. Due to the airway problems encountered with thyroid disease, thyroidectomy under local anesthesia was advocated by some anesthesiologists.[10] However, a patient with huge thyroid causing compromised airway is a major limiting factor for this technique too.

Use of cardiopulmonary bypass for maintaining tissue oxygenationhasalsobeendescribedincasesof difficultairway with huge, compressive thyroid masses where airway maintenancewasdifficult.[11]

The safe options of airway management left in our case were as follow: Awake FOI or ventilation via rigid bronchoscopy. Ventilation through a rigid bronchosope is more helpful in patients with mid to lower tracheal obstruction and when endotracheal intubation is not possible.[6] Emergency femoro-femoral bypass was kept as a backup plan in event of severe airway compromise or cardio-respiratory event. The most viable option left in our casewasfiberopticintubation.Eldawlatlyet al.[12] reported a case of an obese female with huge goiter presenting with difficultairwaywherethetracheawassuccessfullyintubatedusing FOB and loco-sedative technique. Local anesthesia wasestablishedusing5%lignocainepasteontheposteriorthird of the tongue along with lignocaine nebulization to oropharynx using 4% lignocaine. Intravenous sedationconsisted of midazolam 2 mg and sufentanyl 5 mcg. The combined use of local anesthesia and mild sedation provided with a calm relaxed patient and a smooth intubationwithout significant respiratory compromise.However,thistechniquetooisnotfreeof flaws.Completeairway obstruction during awake FOI has been reported in whom the use of local anesthetic precipitated acute loss of the airway, so that urgent surgical intervention was required.[7] Also, in patients with pre-existing stridor and respiratory compromise, even mild sedation or sedative premedication is avoided to prevent further compromise.[2] Our patient was not having any previous respiratory compromise, so opting for mild sedation was considered better than having an anxious and irritable patient. Evaluating all the pros and cons, we decided to go for the loco-sedative technique for FOI. Loco-sedative technique is the use of local anesthetics for desensitizing the airway, and sedatives are given in sub-anesthetic doses formildanalgesiaandsedation.Weusedlignocaine4%andlignocaine10%foranesthetizingtheairway.Midazolam,fentanyl, and propofol were used as sedatives. The patient tolerated the procedure well.

[Downloaded free from http://www.saudija.org on Tuesday, September 17, 2013, IP: 41.128.165.40]  ||  Click here to download free Android application for this journal

Page | 89Srivastava and Dhiraaj: Airway management in a patient with prolonged enlarged goiter using loco-sedative technique

Saudi Journal of Anaesthesia Vol. 7, Issue 1, January-March 2013

Patient was electively kept intubated for 36 hrs in view of chances of tracheomalacia. She was extubated after cuff deflation demonstrated adequate leak around thetracheal tube while the patient was awake and breathing spontaneously.[13]

CONCLUSION

In conclusion, awake FOI using loco-sedative technique is a viable option in selected group of patients having compromised airway. Preoperative airway assessment couldpredictpatientswithpossibledifficultairway.Properplanning and discussing the problems with the patient and surgeon are important for safe outcome.

REFERENCES

1. Amathieu R, Smail N, Catineau J, Poloujadoff MP, Samii K, Adnet  F.  Difficult  intubation  in  thyroid  surgery:  Myth  or reality? Anesth Analg 2006;103:965‑8.

2. Hariprasad M, Smurthwaite GJ. Management of a known difficult  airway  in  a  morbidly  obese  patient  with  gross supraglottic oedema secondary to thyroid disease. Br J Anaesth 2002;89:927‑30.

3. Chakera A, van Heerden PV, van der Schaaf A. Elective awake intubation in a patient with massive multinodular goitre presenting for radioiodine treatment. Anaesth Intensive Care 2002;30:236‑9.

4. McHenry CR, Piotrowski JJ. Thyroidectomy in patients with marked thyroid enlargement: Airway management, morbidity,

and outcome. Am Surg 1994;60:586‑91.5. Malhotra S, Sodhi V. Anaesthesia for thyroid and parathyroid

surgery. Contin Educ Anaesth Crit Care Pain (2007) 7: 55‑586. Dabbagh A, Mobasseri N, Elyasi H, Gharaei B, Fathololumi M,

Ghasemi M, et al. A rapidly enlarging neck mass: The role of the sitting position in fiberoptic bronchoscopy for difficult intubation. Anesth Analg 2008;107:1627‑9.

7. Shaw IC, Welchew EA, Harrison BJ, Michael S. Complete airway  obstruction  during  awake  fibreoptic  intubation. Anaesthesia 1997;52:582‑5.

8. Lleu JC, Forrler M, Pottecher T, Otteni JC. Retrograde intubation using the subcricoid region. Br J Anaesth 1992;69:542.

9. Boucek CD, Gunnerson HB, Tullock WC. Percutaneous transtracheal high‑frequency jet ventilation as an aid to fibreoptic intubation. Anesthesiology 1987;67:247‑9.

10. Spanknebel K, Chabor JA, DiGiorgi M, Cheung K, Lee S, Allendorf J, et al. Thyroidectomy using local anesthesia: A report of 1,025 cases over 16 years. J Am Coll Surg 2005;201:375‑85.

11.  Belmont  MJ, Wax MK,  DeSouza  FN.  The  difficult  airway: Cardiopulmonary bypass‑the ultimate solution. Head Neck 1998;20:266‑9.

12. Eldawlatly A, Alsaif A, AlKattan A, Turkistani A, Hajjar W, Bokhari A, et al. Difficult airway in a morbidly obese patient with huge goiter: A case report and review of literature. Internet J Anaesthesiology 2007;13:1.

13. Fischer MM, Raper RF. The “cuff‑leak”‑test for extubation. Anaesthesia 1992;47:10‑2.

How to cite this article: Srivastava D, Dhiraaj S. Airway management of a difficult airway due to prolonged enlarged goiter using loco-sedative technique. Saudi J Anaesth 2013;7:86-9.Source of Support: Nil, Conflict of Interest: None declared.

“Quick Response Code” link for full text articles

The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free applications.

[Downloaded free from http://www.saudija.org on Tuesday, September 17, 2013, IP: 41.128.165.40]  ||  Click here to download free Android application for this journal