Extubation of a difficult airway after thyroidectomy: use of a flexible bronchoscope via the LMA-Classic™

We report an extubation strategy for a patient scheduled for thyroidectomy who had several factors indicating that it would be a difficult extubation.

A 75-yr-old man with thyroid cancer presented for total thyroidectomy. He had anatomical features predictive of a difficult upper airway. Therefore, his trachea was intubated while he was awake using a flexible bronchoscope. The tumour had invaded the trachea, necessitating total thyroidectomy, 3-cm tracheal resection, and primary tracheal anastomosis. The left recurrent laryngeal nerve (RLN) was inherently involved in the tumour and sacrificed. A "guardian suture" placed between the chin and the chest maintained the head and neck in flexion, thereby avoiding traction on the tracheal anastomosis. Immediate postoperative extubation was desirable, given the new tracheal anastomosis; however, complicating factors included left RLN paralysis, tracheal anastomosis, potential for tracheomalacia or supraglottic airway swelling, and the guardian suture preventing neck extension. In addition, there were anatomical features raising the suspicion of difficult reintubation should it be necessary. With the patient deeply anesthetized, the endotracheal tube was removed and replaced with the Laryngeal Mask Airway (LMA)-Classic™ as a bridging device to facilitate bronchoscopic examination. It allowed us to visualize the tracheal repair, tracheal movement, vocal cord function, and supraglottic structures. The patient emerged from anesthesia and was extubated uneventfully.

We describe a viable extubation strategy used in a patient after complex thyroid surgery involving tracheal resection. By using the LMA-Classic™ as a bridging device and to facilitate bronchoscopic examination, we were able to address the above concerns and safely manage the extubation phase in this patient.