Extubation-related respiratory compromise in patients with large goitres: Case-based insights

Dear Editor,

We present two cases of large goitres associated with peri-extubation respiratory compromise to highlight the limitations of commonly used extubation predictors and the importance of intraoperative airway reassessment. A 67-year-old woman presented with progressive breathlessness, dysphagia to solids for three months, and a 20-year history of neck swelling. She reported choking in the supine position but no stridor or orthopnoea. She had been recently diagnosed with hyperthyroidism that was controlled with oral carbimazole and propranolol. Examination revealed a 10 × 8 cm right-sided neck mass extending retrosternally, with restricted neck movement and a Mallampati grade II airway [Figures 1a-b]. Oxygen saturation was 93% on room air. Computed tomography (CT) imaging showed a multinodular goitre extending into the mediastinum up to the right atrium, compressing the trachea to 1.1 cm at the T1–T2 level. Pulmonary function tests demonstrated a restrictive pattern. Preoperative laryngoscopic examination showed normal vocal cord mobility. A multidisciplinary team planned a total thyroidectomy with awake fibreoptic intubation. The airway was prepared with lignocaine nebulisation, nasal pledgets, oropharyngeal spray, and bilateral superior laryngeal nerve blocks. The anatomical landmark for the right superior laryngeal nerve block was not easily palpable due to the large goitre; hence, the block was given under ultrasonography (USG) guidance through the gland on the right side. Awake fibreoptic intubation was successfully performed using a 7.0 mm (internal diameter) flexometallic tube, passed beyond the compressed tracheal segment. General anaesthesia was induced with propofol, fentanyl, and vecuronium, administered only after confirming correct tube placement and adequate ventilation. Surgery proceeded uneventfully, and surgeons noted intact tracheal rings. At the end of surgery, the leak test was negative, and vocal cord movement was normal. The patient was extubated awake in a semi-recumbent position. Shortly after extubation, she developed respiratory distress and was reintubated using videolaryngoscopy. Reintubation was performed without additional airway anaesthesia, as the airway remained adequately anaesthetised from the initial topicalisation and bilateral superior laryngeal nerve blocks. Although not routinely required post-thyroidectomy, videolaryngoscopy was invaluable in this emergency for prompt airway management. A CT chest showed bilateral basal atelectasis and signs of tracheomalacia. She was extubated on postoperative day 1 and required non-invasive ventilation for three days. Oxygen support was gradually weaned, and she was discharged on postoperative day 6 without further complications.

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Figure 1:

Appearance of the first patient. (a): Front view, (b): Lateral view

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Another case of a 57-year-old male with a diffusely enlarged thyroid (10 × 3 × 4 cm) [Figures 2a-b] with euthyroid status and normal vocal cord mobility on indirect laryngoscopy who presented without any respiratory compromise was planned for total thyroidectomy. As the patient was asymptomatic with no significant tracheal narrowing on imaging, awake intubation was not deemed necessary, and specific airway blocks were therefore not administered. Induction was performed using intravenous agents (propofol and fentanyl). Succinylcholine was administered to aid intubation. There was no airway collapse observed during induction. The Video Laryngoscopy 3 Reusable (VL3R) device was used, allowing clear visualisation and smooth intubation. A collective decision for extubation was taken due to an uneventful intraoperative period and a negative leak test. However, a check with a fibreoptic bronchoscope revealed tracheal collapse during inspiration, and the surgeons also noted a soft and pliable trachea during surgery, incapable of withstanding and maintaining an airway. Prophylactic tracheostomy was then performed in view of possible prolonged intubation, and the patient was then shifted to the intensive care unit (ICU) for further mechanical ventilation and monitoring.

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Figure 2:

Appearance of the second patient. (a): Front view, (b): Lateral view

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Huge goitres and retrosternal goitres, such as the ones that we encountered, can remain asymptomatic for years before presenting with airway compromise.^[1] Symptoms like dyspnoea and dysphagia often correlate with imaging findings of tracheal narrowing.^[2] Anaesthetic challenges include airway obstruction, tracheal deviation, potential cardiovascular compromise, and postoperative airway collapse.^[3]

Awake fibreoptic intubation remains the technique of choice when imaging reveals significant airway compression.^[1] Maintaining spontaneous ventilation is crucial until the airway is secured.^[4] Extubation carries risk, especially when tracheomalacia or prolonged tracheal compression exists.^[5] The leak test was negative in both our cases; however, our first patient developed respiratory compromise post-extubation, likely due to undiagnosed tracheomalacia. This case emphasises the importance of incorporating preoperative imaging when planning extubation.^[3] Delayed extubation may be safer in patients with significant retrosternal extension and tracheal compression. The second patient also would have developed respiratory distress after extubation if we had believed the results of the leak test and extubated him. Fortunately, the fibreoptic bronchoscopy showed the collapse of the tracheal walls, which cautioned us against extubation on the table.

Our experience highlights the importance of anticipating airway-related complications in patients with huge goitres. Awake fibreoptic intubation ensures safe airway control, but the risk of postoperative tracheomalacia requires a cautious extubation strategy and close monitoring.^[6] Further, a negative leak test should not be the gospel for extubation in patients with a huge thyroid. Although the leak test is useful in assessing post-extubation laryngeal oedema, it does not reliably exclude tracheomalacia, which may require dynamic airway evaluation. Dynamic flexible bronchoscopy remains the gold standard for diagnosing tracheomalacia, while dynamic CT imaging can serve as a useful adjunct. Patients with suspected tracheomalacia based on imaging or intraoperative findings may benefit from delayed extubation under ICU observation. Dynamic airway evaluation should guide timing for extubation.