Goitre and difficulty of tracheal intubation

To assess the difficulty in both laryngoscopy and tracheal intubation related to goitre and to identify factors predictive of difficult intubation due to this condition.

Prospective observational.

We used the Intubation Difficulty Scale (IDS) in 80 consecutive patients with large goitre (defined by the inability to palpate the cricoid cartilage, the presence of endothoracic goitre, tracheal deviation of more than 1cm or tracheal stenosis on the chest x-ray) and 77 control patients.

Cormack grades 3-4 were more frequent at initial laryngoscopy in patients with goitre (23/80 vs. 9/77; p<0.05), but the difference was no longer significant after application of an external laryngeal pressure (8/80 vs. 5/77). IDS scores (median [25th-75th percentiles]) were higher in the goitre group (1 [0 - 4]) than in the control group (0 [0 - 1]; p=0.001), corresponding to an increase in slightly difficult intubation (IDS 1-5: 36/80 vs. 15/77; p<0.05). However, incidence of moderate to major difficulty in intubation (IDS>5: 8/80 vs. 7/77) as well as time to completion of intubation were similar in both groups. Tracheal stenosis (> or =30%) and reduced mouth opening (<4.4cm) were the only significant predictors of increased difficulty in intubation in patients with a goitre.

Large goitres are usually associated with slight difficulty in intubation only. Increased difficulty should be expected when severe tracheal stenosis is present on chest x-ray, especially when associated with a reduced mouth opening.