• Ji-Yoon Kim, Ji-Yong Yeom, Si-Jeong Youn, Jeong-Eun Lee, Jin-Young Oh, and Sung-Hye Byun.
• Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea.
• Medicine (Baltimore). 2022 Mar 11; 101 (10): e29041e29041.

RationaleGoiter, an abnormal enlargement of the thyroid gland, can induce airway distortion or tracheal compression. Airway management can be challenging for anesthesiologists, depending on the location and size of the mass as well as the patient's airway conditions, although it is reported that most cases can easily be managed by oral intubation.Patient ConcernsA 61-year-old female patient who had planned for a total thyroidectomy due to a huge goiter was intubated with nerve integrity monitoring (NIM) tubes, using video laryngoscopy (VL) and oral fiberoptic bronchoscopy (FOB) alone. The respective attempts initially failed.DiagnosisThe patient's thyroid mass extended from the C3 cervical spine level to the T1 thoracic spine level with retropharyngeal involvement, causing an upper airway anatomical alteration that made intubation difficult. FOB manipulation was challenging due to the acute angulation of the laryngeal inlet and the tongue and the consequent interruption by the epiglottis. There was resistance to tube introduction, despite counterclockwise rotation of the NIM tube, due to acute angulation of the larynx and circumferential narrowing of the oropharyngeal and supraglottic space.InterventionsIn the first step of FOB-guided intubation, external laryngeal manipulation (ELM) was performed to improve the angle of the glottic opening and to elevate epiglottis tip. This allowed for FOB introduction into the trachea. VL was then performed transorally to elevate the tongue base and increase space, using the blade. ELM was applied simultaneously to move the glottis lower, thereby reducing the angle of the tube passage.OutcomesThe NIM tube was successfully introduced into the trachea with counterclockwise rotation in FOB-guided intubation.LessonsThe combination of techniques using basic and popular devices and maneuvers, such as ELM and VL, may be useful for the successful management of difficult airways related to retropharyngeal goiter, without the need for surgical airway.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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