Anesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing: the challenges imposed -A case report-

Abstract

Anesthetic management of patients with mediastinal masses remains challenging as acute cardiorespiratory decompensation may follow induction of anesthesia. We describe a 57 year old lady with massive retrosternal goiter and severe intrathoracic tracheal compression who had a total thyroidectomy. Comprehensive contingency plans were an essential prerequisite for successful management of difficult airway, including multidisciplinary involvement of otorhinolaryngologic and cardiothoracic surgeons preparing for rigid bronchoscopy and cardiopulmonary bypass. Awake oral fiberoptic intubation was performed under dexmedetomidine sedation. Severe tracheal narrowing necessitated usage of a 5.0 mm uncuffed flexometallic endotracheal tube. Anesthesia was maintained with sevoflurane and dexmedetomidine infusion with target controlled infusion of remifentanil as analgesia. No muscle relaxant was given. Surgical manipulation led to intermittent total tracheal compression and inadequate ventilation. The tumor was successfully removed via the cervical approach. A close working relationship between anesthesiologists and surgeons was the key to the safe use of anesthesia and uneventful recovery of this patient.

Ketamine-Propofol (Ketofol) as a Viable Alternative in a Septic Patient with Mediastinal Mass Requiring General Anesthesia for Endoscopic Retrograde Cholangio-Pancreatography

“…Distortion of airway can make intubation difficult. In view of all these potential and uncertain risk because of incomplete evaluation, we decided to provide anesthesia by preserving the muscle tone and by maintaining spontaneous ventilation in the lateral position, which is considered safe technique in presence of mediastinal mass [5][6][7][8][9] . Oxygen was administered using nasal prongs at 3L/min.…”

Difficult airway challenges-intubation and extubation matters in a case of large goiter with retrosternal extension

“…and Tan and Esa stated in their studies that awake fiberoptic intubation offers more hemodynamic stability, better patient tolerance and patency of the airway. [ 10 11 ] Ghai et al . suggested that early fiberoptic intubation should be planned when there is suspicion of significant airway obstruction.…”

Multidisciplinary Management of Airway Obstruction and Superior Vena Cava Obstruction Secondary to Huge Retrosternal Goiter

“…Anesthetic management of patients with mediastinal masses such as huge retrosternal goiter remains very challenging as acute intraoperative or postoperative cardiorespiratory decompensation and critical hemodynamic situation might occur that may results in death after induction of general anesthesia [21][22][23].…”