Fiberoptic-guided nerve integrity monitoring tube intubation assisted by video-laryngoscope with external laryngeal manipulation in a patient with anteriorly displaced larynx due to huge goiter with retropharyngeal involvement: A case report.

RATIONALE

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.

PATIENT CONCERNS

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.

DIAGNOSIS

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.

INTERVENTIONS

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.

OUTCOMES

The NIM tube was successfully introduced into the trachea with counterclockwise rotation in FOB-guided intubation.

LESSONS

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.