Airway Management In A Difficult Intubation Due To The Presence Of A Goiter
Jevaughn Davis MD1*, Caitlyn Stewart2, Haianha Desamour MD 1, Eric Heinz MD PhD3, Anita Vincent MD3
1AResident Physician, Department of Anesthesiology and Critical Care, George Washington School of Medicine and Health Sciences, Washington DC, USA
2Medical Student, George Washington School of Medicine and Health Sciences, Washington DC
3Attending Physician, Assistant Professor, Department of Anesthesiology and Critical Care, George Washington School of Medicine and Health Sciences, Washington DC 20037
Jevaughn Davis, MD Resident Physician, Department of Anesthesiology and Critical Care, George Washington School of Medicine and Health Sciences, Washington DC, USA
Figure 1: Neck Goiter.
Admission two view chest x-ray was notable for tracheal deviation and subglottic narrowing (Figure 2A/B). The anesthesia team peri-operatively evaluated her, wherein she was a mallampati class II and she denied respiratory symptoms or trouble with lying flat. Beside ultrasound revealed a vascular mass with a patent trachea while upright and moderate compression when the head of the bed was less than 30 degrees. Trauma surgery was consulted for a surgical airway should intubation attempts prove unsuccessful. Trauma surgery determined the borders of the mass were unclear and expressed concerns that if intubation failed and urgent surgical exploration needed, a surgical airway would be challenging and potentially unsuccessful given the unknown anatomy. They determined the mass to be hypervascular, and a surgical airway could lead to massive hemorrhage. The case was moved to another day for a more robust evaluation of the neck mass.
Figure 2: Tracheal deviation to right and airway compression. A: Chest x-ray, left lateral view. B: Chest x-ray, frontal view.
Ultrasound revealed a markedly enlarged thyroid gland compatible with a goiter containing multiple enlarged nodules with two right nodules measuring 5.2 x 4 x 5 cm and 5.2 x 4 x 4.2 cm in addition to a left nodule measuring 5.6 x 4.6 x 5.2 cm. The thyroid was enlarged and heterogeneous with multiple coarse calcifications with the left lobe measuring 11.4 x 6.3 x 7.9 cm and right lobe measuring 8.6 x 5.2 x 4.7 cm. All nodules were heterogeneous with solid, mixed solid, cystic, and calcified parts. A computerized tomography (CT) neck and soft tissue scan was performed and demonstrated an enlarged heterogeneous thyroid gland with multiple coarse calcifications with the left lobe greater than right lobe (Figure 3). The left lobe measures 11.4 x 6.3 x 7.9 cm and the right lobe measures 8.6 x 5.2 x 4.7 cm, with the largest nodule in the right gland measuring 6.0 x 4.0 x 4.7 cm the upper /mid pole (Figure 4A/B).
Figure 3: Computed tomography scan of the goiter.
Figure 4: Computed tomography soft tissue scan demonstrating the Right and Left nodules of the goiter. A: Coronal cross-sectional view. B: Sagittal cross-sectional view.
On CT neck and soft tissue, the airway proved to be largely patent with regions of luminal narrowing (Figure 5). Otorhinolaryngology performed a flexible fiberoptic laryngoscopy and discovered a widely patent airway without significant airway compression. Both trauma surgery and otorhinolaryngology surgery opted to be available for intubation.
Figure 5: Computed tomography neck and soft tissue scan demonstrating the airway. Sagittal view, red arrow represents the area of mild narrowing.
The decision was made to perform an awake fiberoptic intubation for patient safety in the setting of a possible difficult intubation. Induction began with 0.4 mg IV glycopyrrolate and nebulized 5% lidocaine in the preoperative area for 30 minutes. The patient was then taken to the operating room, where she was placed on standard monitors in addition to nasal cannula with capnography. A remifentanil infusion was started at 0.07mcg/kg/min and topical 4% lidocaine gel was administered bilaterally to the tonsillar pillars. After about seven minutes, the fiberoptic scope was introduced; however, despite the absence of a gag or cough reflex, the scope could not be advanced without the patient’s tongue actively fighting provider efforts. A second attempt was made with jaw lift and tongue retraction, however the patient’s tongue continued to interfere with fiberoptic scope advancement. The decision was made to abandon awake fiberoptic intubation since the patient was easily masked. Anesthesia was induced with 8% sevoflurane in oxygen with the patient in a semi-recumbent position and anesthesia was maintained with 50% oxygen and sevoflurane for a minimum alveolar concentration of 1.2 after intubation. A 7.0 reinforced endotracheal tube was inserted with the aid of a C-MAC video laryngoscope after obtaining a grade 2 Cormack and Lehane view. After confirmation of placement with end-tidal carbon dioxide, paralytic was administered (30 mg IV Rocuronium) for the surgical procedure. Additionally, the patient was given 10 mg IV Dexamethasone, 4 mg IV Ondansetron, 40 mg IV Ketamine, 2g IV Ancef, and 0.7 mg IV Hydromorphone during the case. Neuromuscular train-of-four ratio was continuously monitored and at the end of the case, the patient was reversed with 200 mg IV Sugammadex and a train-of-four with height greater than 0.9 was obtained. After full inhalational agent washout, the patient met extubation criteria and was extubated to nasal cannula without issues. In the post anesthesia care unit (PACU), she was maintained on nasal cannula with capnography in the event additional IV opioids were needed for operative pain. A fascia iliaca nerve block was placed for further pain control to minimize opioid usage. PACU stay was uneventful, and she returned to her inpatient room.
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