Video Laryngoscopy an Alternative to FOB for Securing the Airway of Retrosternal Goiter in a Reactive Airway Disease Patient: A Case Report

International Clinical and Medical Case Reports Journal Case Report (ISSN: 2832-5788) Int Clinc Med Case Rep Jour (ICMCRJ) 2025 | Volume 4 | Issue 10 Video Laryngoscopy an Alternative to FOB for Securing the Airway of Retrosternal Goiter in a Reactive Airway Disease Patient: A Case Report Dr. Rahul Sarkar MD*, Dr. Tapas Mandal MD, Dr. Deepak Koli MD, Dr. Hemant Mehta MD Sir HN Reliance Foundation Hospital, Girgoan Mumbai400004, Maharashtra, India Citation: Rahul Sarkar,Tapas Mandal, Deepak Koli, Hemant Mehta. Video Laryngoscopy an Alternative to FOB for Securing the Airway of Retrosternal Goiter in a Reactive Airway Disease Patient: A Case Report. Int Clinc Med Case Rep Jour. 2025;4(10):1-5. Received Date: 26 October 2025; Accepted Date: 27 September 2025; Published Date: 28 October 2025 *Corresponding author: Dr. Rahul Sarkar MD, Sir HN Reliance Foundation Hospital, Girgoan Mumbai400004, Maharashtra, India Copyright: Dr. Rahul Sarkar MD, Open Access 2025. This article, published in Int Clinc Med Case Rep Jour (ICMCRJ) (Attribution 4.0 International), as described by http://creativecommons.org/licenses/by/4.0/ ABSTRACT Patients presenting with retrosternal goitre always pose a challenge in securing the airway. Fibreoptic intubation despite being the gold standard requires expertise training , availability at all centres with increased exposure to the lower airway. Computed tomography (CT) scan provides accurate information on the extent of the goitre in aid to the surrounding compression, a comprehensive preoperative assessment can help plan to secure a difficult airway giving an alternative plan to use of fibreoptic intubation. Keywords: Computed tomography scan, Difficult airway, Fibreoptic intubation, Retrosternal goitre, Tracheal compression, Video laryngoscopy. INTRODUCTION [1]The degree & extent of enlarged thyroid gland causes displacement and compression of trachea and surrounding blood vessels. The symptoms may range from dyspnoea to position changes, predisposing these patients to further lower airway reactive diseases & frequent upper respiratory tract infections. [2] This leads to challenges for the anesthesiologist as a difficult to ventilate and intubate case scenario. [3] Therefore, adequate assessment of the extent of the retrosternal goitre and the degree of tracheal compression is important part of the preoperative assessment. [4] Computed tomography (CT) scan gives an accurate measurement of the narrowest tracheal diameter at the site of compression along with the details of tracheal deviation and compression of other structures. Here we present a case report with tracheal deviation and compression airway was secured using video laryngoscopy following the CT findings preoperatively and fibreoptic was avoided giving us an alternative plan. CASE HISTORY A 67-year-old, gentleman presented with complaints of incidental swelling in the neck gradually increased since 3 months to the current size followed by hoarseness of voice and difficulty in deglutition since 1 month, known case of hypertension and bronchial asthma on nebulisations. International Clinical and Medical Case Reports Journal Case Report (ISSN: 2832-5788) Int Clinc Med Case Rep Jour (ICMCRJ) 2025 | Volume 4 | Issue 10 On examination, a firm and immobile swelling measuring approximately 7 x 8 cms. The lower border was not palpable. The swelling moved with deglutition. There was no movement of swelling with protrusion of tongue. HRCT Chest : Retrosternal extension of the swelling was noted with compression of trachea along with deviation to the right compression and minimum tracheal diameter of 6.2 mm at the narrowest point. There was ? positive lymphadenopathy and vessels were normal. Laboratory examination and thyroid function test were wnl, pulmonary function test showed: Moderate restrictive pattern with poor reversibility to bronchodilators, Indirect laryngoscopy : left vocal cord paralaysis was noted, Ecg: rbbb with 1-2 vpc sinus tachycardia. 2D ECHO: EF 60%, wnl CXR: Bilateral lower lobe haziness with? right lower lobe opacity ? microaspirations Trachea deviated to the right Patient was planned for intraoperative neuromonitoring with total thyroidectomy & sternotomy. Preoperatively Procedure was explained to the patient and relatives with high risk consent , MDT approach undertaken with pulmonologist with proper antibiotic coverage for 10 days and icu backup kept.Upon arrival in the operation theatre, ASA graded standard monitors were attached : ECG, NIBP, SPO2, capnography, BIS electrodes attached. Difficult airway trolley with fibreoptic bronchoscopes, IgeL, I-l=Lma, working suctions, FONA equipment kept ready. 2 peripheral wide bore on upperlimb secured .Patient was kept supine with 10 degree head elevation and table tilted to left 5 degree , Preoxygentaion with 6l o2 via Hudson mask started , inj dexmetomidine ( 2mcg/ml) started at 0.8 ml/kg/hr, At the outset, 10 mg Ketamine and 30 mcg fentanyl, 60 mg preservative free lignocaine iv, paracetamol 1000 mg , tramadol 50 mg , dexamethasone 8 mg with 100 mg hydrocortisone ,1 mg midazolam administered, a preliminary awake laryngoscopy using C-MAC® video-laryngoscope (Karl Storz EndoscopyAmerica, CA, USA) revealed a vocal cord visualisation with left cord immobility and right cord mobile. Subsequently 150 mg propofol titrated gradually, observing with BIS : 40 and confirming mask ventilation on capnography , 75 mg succinylcholine administered ,a C-MAC® video-laryngoscope no: 4 (Karl Storz Endoscopy-America, CA, CL GRADE 3 using an armored NIMS endotracheal tube (size 7.0 internal diameter) which was advanced over the Eschmann stylet and with the contact surface over the vocal cords without any difficulty. Confirmation was done by auscultation of the bilateral breath sounds and capnography. Patient was kept on TIVA with maintenance : inj dexmetomidine( 0.5 mcg/ml/kg/hr) and TCI propofol( 10mg/kg) MARSH model started, no inhalational agent used, no long acting muscle relaxant used , ventilatory parameters: (PCV-VG TV: 400, RR; 14, FIO2: 0.4,PEEP;6) O2 + AIR BIS kept around 40-60, intraoperative left recurrent laryngeal nerve monitoring done , intermittent fentanyl doses of 2 mcg/ml were given to respond to surgical stress responses , The intraoperative procedure was uneventful , I/o: 2000 plasmalyte with urine : 1200 ml blood loss : 300 ml noted , hgt: 133 mg/dl , Post procedure cuff leak test done which showed leak +, A CHECK DLscopy done : left vocal cord immobile+ , right cord mobile+ ,after returning to spontaneous ventilation over an airway exchange catheter the patient was extubated, with mild titrated doses of esmolol 1 mg/kg to blunt extubation response. Patient was kept in ICU 24hrs for observation. International Clinical and Medical Case Reports Journal Case Report (ISSN: 2832-5788) Int Clinc Med Case Rep Jour (ICMCRJ) 2025 | Volume 4 | Issue 10 Figure 1: HRCT of Chest Figure 2: X-RAY CHEST DISCUSSION [5] Though fibreoptic bronchoscopy is the gold standard for intubation [6] but in patients with wheezing or airway obstruction, the fibreoptic bronchoscope procedure may impede and cause reactive airway. Therefore, the application of this technique in patients with severe tracheal obstruction is controversial. [7] Bennett et al. International Clinical and Medical Case Reports Journal Case Report (ISSN: 2832-5788) Int Clinc Med Case Rep Jour (ICMCRJ) 2025 | Volume 4 | Issue 10 reported that only 6 out of 1,969 patients undergoing thyroid surgery had difficult airways for tracheal intubation. [8] In another study by Gilfillan et al., of the patients expected to have difficult airways preoperatively, 87% patients were successfully intubated under direct laryngoscopy. [9] In the study by Pan et al., all patients completed tracheal intubation with video laryngoscopy, even cases with tracheal diameter of less than 1 cm. [10] Thus, careful preoperative assessment may enable the anesthesiologist to intubate the patient under video laryngoscopy and avoid the use of fibreoptic intubation. CT scan is highly valuable in the preoperative evaluation of the patient as it gives accurate details about the thyroid size, the extent of the swelling in the substernal and mediastinal regions and the extent of invasion into surrounding tissues [11,12] CONCLUSION Preoperative CT scan is vital in patients with retrosternal goitre, planned for thyroidectomy. Careful assessment of the deviation of trachea and compression of the surrounding structures can help in proper planning to secure the airway while minimizing the need of procedures like fibreoptic intubation which can help to avoid further manipulation over a lower airway reactive disease patient. REFERENCES 1. Shaha AR. Substernal goiter: What is in a definition? Surgery 2010;147:239–240. 2. Batra YK, Gupta SK, Rajeev S. Tracheomalacia due to short term ventilation after total hip arthroplasty in an adult with long standing goiter. Anesth Analg 2007;105(6):1867–1868. 3. Chen AY, Bernet VJ, Carty SE, Davies TF, Ganly I, Inabnet WB 3rd, et al. American Thyroid Association statement on optimal surgical management of goiter. Thyroid 2014;24:181–189. 4. Testini M, Nacchiero M, Miniello S, Ianora AS, Piccinni G, Venere BD et al. Management of retrosternal goiters: experience of a surgical unit. Int Surg 2005;90:61–65. 5. Sulaiman A, Lutfi A, Ikram M, Fatimi S, Bin Pervez M, Shamim F, et al. Tracheomalacia after thyroidectomy for retrosternal goitres requiring sternotomya myth or reality? Ann R Coll Surg Engl 2021;103:504-507. 6. Heidegger T, Gerig HJ. Algorithms for management of the difficult airway. Curr Opin Anaesthesiol 2004;17:483–484. 7. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106:617–631. 8. Bennett AM, Hashmi SM, Premachandra DJ, Wright MM. The myth of tracheomalacia and difficult intubation in cases of retrosternal goitre. J Laryngol Otol 2004;118:778–780. 9. Gilfillan N, Ball CM, Myles PS, Serpell J, Johnson WR, Paul E. A cohort and database study of airway management in patients undergoing thyroidectomy for retrosternal goitre. Anaesth Intensive Care 2014;42:700–708. 10. Pan Y, Chen C, Yu L, Zhu S, Zheng Y. Airway Management of Retrosternal Goiters in 22 Cases in a Tertiary Referral Center. Ther Clin Risk Manag 2020;16:1267-1273. International Clinical and Medical Case Reports Journal Case Report (ISSN: 2832-5788) Int Clinc Med Case Rep Jour (ICMCRJ) 2025 | Volume 4 | Issue 10 11. Bayhan Z, Zeren S, Ucar BI, Ozbay I, Sonmez Y, Mestan M, et al. Emergency thyroidectomy: Due to acute respiratory failure. Int J Surg Case Rep 2014;5:1251-1253. 12. Cagli K, Ulas MM, Hizarci M, Sener E. Substernal goiter: an unusual cause of respiratory failure after coronary artery bypass grafting. Tex Heart Inst J 2005;32:224-227.