Airway Management for Tracheal Perforation After Left Hemi-Thyroid Lobectomy: A Case Report

BACKGROUND Tracheal perforation, although rare, poses significant challenges for anesthesiologists following thyroid surgery, often necessitating complex airway management under general anesthesia. There is limited literature on effective strategies for managing airway complications in these patients. This report details a case of successful airway management using awake fiberoptic intubation in a patient with tracheal perforation and necrosis following a thyroidectomy. CASE REPORT A 65-year-old woman developed tracheal perforation 6 months after left hemi-thyroid lobectomy. She presented with symptoms of sore throat and neck swelling. Preoperative exams revealed an erosive tracheal perforation (3 cm) on the left side, immediately below the glottis. She was scheduled for an urgent tracheostomy under general anesthesia. A multidisciplinary team discussed various airway management strategies, including awake fiberoptic intubation, awake tracheostomy, and extracorporeal membrane oxygenation. Due to the adequate distance between the perforation and the tracheal bifurcation, awake fiberoptic intubation was selected. In the operating room, the bronchoscope was carefully advanced below the perforation site, and the endotracheal tube was then gently passed over the bronchoscope, ensuring the cuff did not disturb the perforation. The tube was positioned with its tip just above the tracheal bifurcation, and general anesthesia was subsequently initiated. Postoperative histological analysis of the tissue obtained during the tracheostomy revealed squamous cell carcinoma, suggesting that malignancy-related tracheal necrosis may have contributed to the perforation. CONCLUSIONS We report successful airway management in a patient with tracheal perforation following left hemi-thyroid lobectomy. Awake fiberoptic intubation proved to be an essential technique for managing such complex cases.