EDEMA

• Intubation generally proceeds well in patients with large cervical and substernal goiters:
  • But occasionally it can be difficult
• When difficult, anesthesia induction and intubation can represent a dramatic and life-threatening process:
  • Given the fact that emergent or “under local” tracheotomies:
    • Generally are not options because of the mass of the overlying goiter
• In patients with goiter:
  • There may be evidence of substantial laryngeal deviation and perhaps vocal cord paralysis at intubation
• The surgeon who performs the preoperative laryngoscopy should convey all information regarding the appearance of the:
  • Larynx, presence of deviation, and vocal cord paralysis to the anesthesia staff
  • Both the surgeon and the anesthesiologist should review the preoperative CT scans and examine the patient together before induction:
    • The method of intubation and the size of the tube and contingency plans can be discussed and decided upon through these discussions
• Typically, a straightforward induction with transoral intubation can be performed:
  • Laryngeal deviation generally does not represent a problem, and tracheal compression generally yields to a reasonably sized endotracheal tube
• An alternative and safe method that we favor is an:
  • Awake, sitting up, fiberoptic trans-nasal intubation:
    • This is especially a reasonable course of action if there is any doubt as to the adequacy of a sedated mask anesthesia airway, particularly if the larynx is significantly deviated by the cervical component of the goiter
• Newer video laryngoscopes are also an excellent adjunct for intubation in such patients
• Maximum tracheal compression in cervical and substernal goiter:
  • Usually occurs at the thoracic inlet but may be present further distally
• As previously noted, tracheal compression by benign goiter typically yields to a reasonably sized endotracheal tube:
  • One exception is when there is malignant infiltration of the trachea, especially if there is intraluminal disease:
    • In these circumstances, transoral bronchoscopic intubation with bronchoscopic core-out can lead to satisfactory airway
• Once again, preoperative CT scanning empowers the surgeon
• Vigilance and recognition of non-thyroid factors, such as:
  • Jaw and tongue size, anteriorly positioned larynx, and available degree of head extension:
    • Are also important determinants of difficult intubation
• Experience has shown that a significant problem in patients with large cervical or substernal goiters:
  • Especially with bilateral circumferential goiters:
    • Is the development of laryngeal edema with initial intubation attempts by anesthesia
    • The larynx, which represents the extreme distal end of the airway projected into the hypopharynx:
      • Likely has chronically reduced venous and lymphatic drainage as a result of a large, constricting bilateral goiter:
        • Such a larynx is easily made edematous with multiple unsuccessful intubation attempts:
          • This edema can last weeks postoperatively:
            • Sometimes requiring tracheotomy, which usually can be removed after such edema resolves:
              • It is therefore best to intubate once correctly
• Intubation problems, although rare, can quickly spell disaster
• The propensity for laryngeal edema from intubation attempts with goiter has been emphasized in the case reports of Hassard:
  • In there series of 200 patients with goiter, they encountered difficult intubation in only four cases (2%)
  • There were no significant predictors of difficult intubation, including size, substernal extension, preoperative compressive symptoms, or radiographic presence of tracheal deviation or compression
  • Tracheotomy was performed in only 3% of patients and was done electively at the time of thyroidectomy
    • Tracheotomy was performed either because of concern about laryngeal edema from multiple intubation attempts or in cases where vocal cord dysfunction was in question in cases without neural monitoring, especially if one vocal cord was known to be paralyzed preoperatively
    • With neural monitoring, greater certainty exists as to the functional status of both nerves during surgery

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