Huge multinodular goiter with mid trachea obstruction: indication for fiberoptic intubation

Goiter or thyromegaly is one of the most common causes of mid tracheal obstruction (external compression or stenosis), which may be associated with difficult larynx visualization and/or difficult airway management, depending on the goiter size, type and ingrowth into the surrounding tissue. Iodine deficiency disorders are still one of the most common causes of goiter in the population of the African continent. These patients with goiter generally present for medical examination at an advanced stage of the disease. Mallampati test, thyromental distance and inter-incisor gap appear to provide the optimal combination for prediction of difficult visualization of the larynx. Video laryngoscopy examination of the subglottic region and inspection of tracheal deviation in the presence of tracheal compression without detected stenosis of the trachea is a standard and preferred technique in comparison with direct laryngoscopy. Intubation can be performed when vocal cords are visualized. The major difficulty on intubation is encountered in only 5.3% of patients with goiter. Large goiter need not always be associated with a higher incidence of difficult endotracheal intubation. Only two predicting factors for difficult airway assessment were identified in these patients: cancerous goiter (especially if compressive signs are present) and Cormack and Lehane grade III/IV. The indication for fiberoptic intubation is tracheal compression or initial tracheal stenosis. Conventional tracheostomy has to be performed in goiter patients with identified tracheomalacia and/or high degree or tracheal stenosis.