Intra-Op Nerve Monitoring for Large Retrosternal Goitre - Anaesthetist's Dilemma

In this report, we describe the successful anaesthetic management and intermittent intraoperative nerve monitoring (IONM) of a patient with a retrosternal goitre that caused severe tracheal compression (more than 70% occlusion) and tested positive for Pemberton's sign. While endotracheal tubes (ETT) with vocal cord surface electrodes are commonly used for IONM, they cannot be used in cases of distal tracheal compression, specifically when the compression occurs 5 cm or more below the vocal cords. In such situations, these neuromonitoring ETTS can get displaced and lose contact with the vocal cords, ultimately undermining their effectiveness. Electrodes attached to the thyroid cartilage can be used to monitor V1-R1-R2-V2 signals in such cases.