Equal and opposite expert opinion. Airway obstruction caused by a retrosternal thyroid mass: management and prospective international expert opinion*

Abstract

Summary Anticipated problems with airway management during anaesthesia require careful planning, particularly when they involve a risk of airway obstruction. Advice may be sought from published literature (usually written by experts) or through direct communication with experts. More frequently, expert involvement is through retrospective review following patient harm. We present the case of a patient suffering from a retrosternal thyroid mass that was compressing her trachea in the midline and dividing it into two 2 × 3 mm lumens. After local discussion the patient underwent thyroidectomy. We invited international experts in anaesthetic airway management to review her case and submit their opinions regarding the best airway management for this difficult case. Opinions differed markedly, mirroring the published literature. Some experts specifically criticised techniques that, unbeknown to them, were proposed by others. The case raises issues about the nature of expert opinion that extends beyond this particular case. The nature and implications of expert opinion, when evidence is absent or conflicting, are discussed.

Progress in management of the obstructed airway

“…Optimal management of the obstructed adult airway remains controversial with no consensus as to the ideal approach. Opinions differ as some experts propose techniques that other experts find unacceptable and explicitly criticise [1][2][3]. There are advocates of inducing general anaesthesia by an inhalational route and avoiding neuromuscular blockade [4]; of inducing general anaesthesia by the intravenous route and using neuromuscular blockade [5]; of avoiding general anaesthesia altogether and securing an airway by an awake fibreoptic intubation technique [6,7]; of tracheostomy under local anaesthesia [8]; or of insertion of a transtracheal catheter under local anaesthesia [9].…”

Obstructing pathology of the upper airway in a post-NAP4 world: time to wake up to its optimal management

“…Maintenance of spontaneous ventilation has been advocated, whereas others recommend intravenous induction with administration of neuromuscular blockade. 18 Implementing the plan for securing the airway in the patient with OAP With the information gleaned from standard and enhanced airway evaluations, a rational plan can be made for safely proceeding with airway management. Expert implementation of the plan is crucial for the patient with OAP.…”

Anaesthetic management of acute airway obstruction

“…These are usually chronic lesions but, in rare circumstances (< 1%), (29) they can present as AAO with considerable management difficulties for the anaesthesiologist, and ENT and thoracic surgeons. (12,30) A goitre can cause a mass effect on surrounding structures, resulting in Pemberton's sign when the gland acts as a 'thyroid cork' at the thoracic inlet and AAO. (31) If large, it can present clinicians with various challenges.…”

“…(4) When Cook et al (30) invited nine international airway experts to give their opinion on the management of AAO due to a retrosternal goitre, there was little consensus on Plan A. However, their Plan Bs almost unanimously recommended a rigid bronchoscope to help secure the airway.…”