Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea.
Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea.
Medicine (Baltimore). 2022 Mar 11;101(10):e29041. doi: 10.1097/MD.0000000000029041.
Goiter, an abnormal enlargement of the thyroid gland, can induce airway distortion or tracheal compression. Airway management can be challenging for anesthesiologists, depending on the location and size of the mass as well as the patient's airway conditions, although it is reported that most cases can easily be managed by oral intubation.
A 61-year-old female patient who had planned for a total thyroidectomy due to a huge goiter was intubated with nerve integrity monitoring (NIM) tubes, using video laryngoscopy (VL) and oral fiberoptic bronchoscopy (FOB) alone. The respective attempts initially failed.
The patient's thyroid mass extended from the C3 cervical spine level to the T1 thoracic spine level with retropharyngeal involvement, causing an upper airway anatomical alteration that made intubation difficult. FOB manipulation was challenging due to the acute angulation of the laryngeal inlet and the tongue and the consequent interruption by the epiglottis. There was resistance to tube introduction, despite counterclockwise rotation of the NIM tube, due to acute angulation of the larynx and circumferential narrowing of the oropharyngeal and supraglottic space.
In the first step of FOB-guided intubation, external laryngeal manipulation (ELM) was performed to improve the angle of the glottic opening and to elevate epiglottis tip. This allowed for FOB introduction into the trachea. VL was then performed transorally to elevate the tongue base and increase space, using the blade. ELM was applied simultaneously to move the glottis lower, thereby reducing the angle of the tube passage.
The NIM tube was successfully introduced into the trachea with counterclockwise rotation in FOB-guided intubation.
The combination of techniques using basic and popular devices and maneuvers, such as ELM and VL, may be useful for the successful management of difficult airways related to retropharyngeal goiter, without the need for surgical airway.
甲状腺肿是甲状腺异常肿大，可以导致气道扭曲或气管受压。气道管理对麻醉医生来说具有挑战性，这取决于肿块的位置和大小以及患者的气道状况，尽管据报道大多数病例可以通过经口插管轻松管理。
一位 61 岁的女性患者因巨大甲状腺肿计划进行全甲状腺切除术，仅使用视频喉镜 (VL) 和经口纤维支气管镜 (FOB) 进行神经完整性监测 (NIM) 管插管，最初尝试均失败。
患者的甲状腺肿块从 C3 颈椎水平延伸至 T1 胸椎水平，伴有咽后受累，导致上呼吸道解剖结构改变，使插管困难。FOB 操作因喉入口和舌的锐角以及会厌的中断而变得具有挑战性。尽管逆时针旋转 NIM 管，但由于喉的锐角和口咽和喉咽空间的环形变窄，导致管引入存在阻力。
在 FOB 引导插管的第一步中，进行了外部喉操纵 (ELM)，以改善声门开口的角度并抬高会厌尖端。这允许 FOB 引入气管。然后经口进行 VL 以使用叶片抬起舌根并增加空间。同时应用 ELM 将声门向下移动，从而减小管通过的角度。
在 FOB 引导插管中，逆时针旋转成功将 NIM 管引入气管。
使用基本和流行设备和操作技术的组合，例如 ELM 和 VL，可能有助于成功管理与咽后甲状腺肿相关的困难气道，而无需进行手术气道。
