Massive Retrosternal Thyroid Swelling: A Supraglottic Solution

Massive thyroid swellings with retrosternal extension pose significant airway challenges due to tracheal compression, deviation, and distortion of normal anatomy. Awake fiberoptic bronchoscopy is the gold standard for anticipated difficult airways; however, failure of this technique, particularly when front-of-neck access (FONA) is not feasible, can rapidly lead to a life-threatening airway emergency. We report the management of a 68-year-old American Society of Anesthesiologists (ASA) physical status III female patient with a large retrosternal thyroid swelling causing positional respiratory distress, scheduled for total thyroidectomy. Imaging revealed a sizeable thyroid mass with significant tracheal deviation and compression. Awake fiberoptic nasal intubation under topical anesthesia and conscious sedation was attempted while maintaining spontaneous ventilation but failed due to poor visualization of the glottis. As invasive airway access was technically challenging because of the mass, a supraglottic airway device (i-gel®) was inserted. The device restored effective oxygenation and served as a stable conduit for fiberoptic-guided tracheal intubation, allowing successful endotracheal tube placement beyond the compressed tracheal segment. Surgery proceeded uneventfully. An elective tracheostomy was performed postoperatively in view of suspected tracheomalacia, and the patient made an uncomplicated recovery. When awake fiberoptic intubation fails and FONA is not feasible, the use of a supraglottic airway device as a conduit for fiberoptic-guided intubation provides a safe and effective alternative. This case highlights the importance of a structured, adaptable airway strategy in patients with massive retrosternal thyroid swellings.