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Retrosternal goitre with tracheal compression for thyroidectomy56-year-old woman, 74 kg, for elective total thyroidectomy for a multinodular goitre

Compressed trachea: goitre airway plan, nerve palsy and neck haematoma

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Know this first

  • Retrosternal goitres compress and deviate the trachea, cause tracheomalacia and SVC obstruction.
  • A large substernal goitre can act like an anterior mediastinal mass and obstruct after induction.
  • Difficult intubation in goitre surgery is 5–8%; goitre size does not predict it.
  • Bilateral recurrent laryngeal nerve injury: stridor or aphonia; reintubate immediately.
  • Neck haematoma: open the clips or sutures and evacuate, as a temporising step.

The patient

56-year-old woman, 74 kg, for elective total thyroidectomy for a multinodular goitre; sternotomy possible. Goitre for 15 years extending behind the sternum; trachea deviated to the right; breathless lying flat. Euthyroid on recent tests. Drugs: none. Vitals: BP 142/86, HR 78, SpO2 97% on air, RR 16. CT: trachea narrowed to 8 mm at the thoracic inlet.

The examiner asks

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  1. Consider

    What are the key issues?

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    • A 56-year-old with a retrosternal goitre narrowing her trachea to 8 mm, for thyroidectomy. Patient
    • Breathless lying flat with a substernal goitre: it may behave like a mediastinal mass at induction. Disease
    • Long compression can soften her tracheal rings, so tracheomalacia may appear after removal. Surgery
    • She must be euthyroid; a thyrotoxic patient is treated first to avoid thyroid storm. Disease
    • The surgeon may need a sternotomy, so cardiothoracic backup is part of the plan. Surgery

  2. Prepare

    How do you assess her?

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    • Thyroid function confirmed normal within recent weeks. Disease
    • I review her CT myself: level, length and narrowest lumen, and how far below the cords it is. Airway
    • Nasendoscopy for cord movement now, as a baseline for any nerve injury.
    • I ask which position eases her breathing; that is my rescue position at induction.
    • SVC signs: facial swelling or distended neck veins change my lines and plan. Disease

  3. Plan

    Awake or asleep, and what tube?

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    • Awake bronchoscopic intubation, placing a reinforced tube beyond the narrowing. Airway
    • Rigid bronchoscope and surgeon in theatre at induction.
    • Spontaneous ventilation kept until the tube is past the compression.
    • Topical lidocaine on her cords spoils NIM signals; her airway wins, so the surgeon stimulates the nerve directly. Surgery
    • Smooth emergence; remifentanil 0.01–0.05 mcg/kg/min reduces coughing on the tube. After surgery
    • Extubation in theatre with everything ready to reintubate in case of tracheomalacia.

  4. Crisis

    Minutes after extubation she has inspiratory stridor and cannot speak. SpO2 88%, RR 30, BP 160/90. What do you do?

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    • Stridor with no voice: bilateral recurrent laryngeal nerve palsy until proven otherwise. Crisis
    • 100% oxygen, sit her up, call the surgeon and senior help.
    • Quick look at the cords; tracheomalacia and haematoma are my other causes.
    • Bilateral palsy needs immediate reintubation, then usually tracheostomy.
    • Videolaryngoscope and smaller tube; rigid bronchoscope for collapsing tracheal rings.
    • ICU; later stridor at 24–96 hours would make me check calcium. After surgery

  5. Crisis

    Next day she was well, but now her neck is swelling fast. She is anxious with stridor; SpO2 91%, BP 170/95, HR 110. What do you do?

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    • Expanding haematoma compressing her airway: call the surgeon and help now. Crisis
    • Clips and sutures opened right there at the bedside; the clot is scooped out.
    • This only buys time; swelling in her pharyngeal tissues can persist.
    • If she still moves air, awake intubation is preferred to induction.
    • Difficult airway trolley and a surgeon ready for emergency tracheostomy.
    • Back to theatre to stop the bleeding, then a monitored bed. After surgery

Fatal mistakes

  • Delaying wound opening for an expanding haematoma.
  • Deep extubation when tracheomalacia is possible.
  • Operating while she is thyrotoxic.
  • Inducing a goitre with mediastinal behaviour without a rigid bronchoscope.

Checked against: Miller 10e · Barash 9e

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Another patient · Medical and endocrine disease. Retrosternal goitre with tracheal compression for thyroidectomy. Same goitre, previously thyrotoxic: bilateral cord palsy after extubation

Know this first

  • Breathlessness when supine or upright predicts airway obstruction under general anaesthesia.
  • Inspiratory flattening on the flow-volume loop means extrathoracic obstruction; delayed expiratory flow means intrathoracic.
  • Difficult intubation in goitre surgery is 5–8%; large substernal goitres behave like anterior mediastinal masses.
  • Bilateral recurrent laryngeal nerve injury causes stridor and needs immediate reintubation.

The patient

52-year-old woman, 74 kg, for elective total thyroidectomy with possible sternal split. Large retrosternal multinodular goitre; breathless lying flat, sleeps on three pillows; trachea deviated to the right. Previously thyrotoxic, euthyroid on methimazole for 3 months; free T4 and TSH normal. Vitals: BP 134/80, HR 78, SpO2 97% on air, RR 16.

The examiner asks

Answer aloud, then press Show.

  1. Consider

    What are your concerns?

    Show the answerHide the answer
    • A 52-year-old with a large retrosternal goitre compressing her trachea, for elective total thyroidectomy. Patient
    • She's euthyroid on methimazole, which elective thyroid surgery requires. Disease
    • Her breathlessness lying flat predicts obstruction once she's anaesthetised. Airway
    • Below the sternum, her goitre can behave like an anterior mediastinal mass at induction.
    • Goitre surgery carries a 5–8% rate of difficult intubation.
    • A sternal split adds bleeding, pneumothorax risk and a longer operation. Surgery

  2. Prepare

    How will you assess her airway?

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    • CT of her neck and chest: the narrowest point, its length and how far down it goes. Airway
    • Flow-volume loops sitting and lying: a flat inspiratory limb is extrathoracic, a slow expiratory limb intrathoracic.
    • Laryngoscopy before surgery to record how her cords move.
    • Echo sitting and lying if the mass could be pressing on her heart. Disease

  3. Plan

    What is your plan for her airway and anaesthetic?

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    • Awake fibreoptic intubation with an armoured tube, sitting up, is my safest option for her. Airway
    • Otherwise, a gas induction keeping her breathing; relaxant withheld until the tube sits beyond the narrowing.
    • If the surgeon uses a NIM tube: no relaxant after intubation and no topical lidocaine on her cords. Surgery
    • A rigid bronchoscope in the room, cardiothoracic surgeons aware and bypass on standby. Airway
    • At the end, a fibreoptic look for tracheomalacia before I decide to extubate.
    • HDU afterwards, watching for neck haematoma, and for low calcium over the next 24–48 hours. After surgery

  4. Crisis

    Minutes after extubation she has loud inspiratory stridor and SpO2 88%. A fibreoptic look shows neither cord moving. What is your management?

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    • Bilateral recurrent laryngeal nerve palsy: both cords lie near the midline and close her glottis. Crisis
    • 100% oxygen, sit her up, and call ENT and senior help now.
    • Reintubate at once with a smaller tube, using the fibreoptic scope or a video laryngoscope. Airway
    • I check the neck for a haematoma; if it's tense, the wound is opened at the bedside. Crisis
    • Later, low calcium can cause stridor too: calcium checked, and 10% gluconate 10–20 mL if low.
    • She stays intubated in ICU; if her cords don't recover, she'll need a tracheostomy. After surgery

Fatal mistakes

  • Giving a relaxant before her compressed airway is secured.
  • Extubating her without a reintubation plan and equipment ready.
  • No surgical or rigid-bronchoscopy backup for a retrosternal goitre.

Checked against: Stoelting 8e · Barash 9e · Miller 10e

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