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Case Report

A Rapidly Enlarging Neck Mass: The Role of theSitting Position in Fiberoptic Bronchoscopy for Difficult Intubation

Ali Dabbagh, MD*

Naseraddin Mobasseri, MD*

Hedayatollah Elyasi, MD*

Babak Gharaei, MD*

Mohammadreza Fathololumi,MD†

Mahshid Ghasemi, MD*

Iman Bandarchi Chamkhale, MD*

Difficult airway management is a dilemma for any anesthesiologist. Althoughpractice guidelines and algorithms may help in such situations, the anesthesi-ologist’s judgment and vigilance remain the primary means to save lives. In thefollowing case, we encountered an acutely enlarging thyroid mass that wascompromising the airway. This huge neck mass precluded tracheostomy underlocal anesthesia, and the patient could breathe only in the sitting position.Therefore, there were few safe strategies for airway management for generalanesthesia. We reiterate the role of awake fiberoptic intubation in suchcircumstances.(Anesth Analg 2008;107:1627–9)

Management of the difficult airway presents agreat dilemma for the anesthesiologist. Practiceguidelines and algorithms may help in such situa-tions. However, the anesthesiologist’s judgment andvigilance remain the primary means to safe airwaymanagement. Neck masses from different sourcesmay affect the airway and are potential causes of a

difficult airway.1– 8 There are few options for secur-ing the airway in a patient with acutely enlargingand airway-compromising anterior neck mass, suchas thyroid tumors. These patients may not tolerate thesupine position due to stridor and tracheal compres-sion. The utility and safety of performing tracheos-tomy in the awake patient prior to induction ofgeneral anesthesia are debatable, due to the location ofthe mass and the displaced anatomy it produces.Awake fiberoptic intubation remains a safe andeffective method in experienced hands. A case of

difficult intubation due to an enlarging neck mass isdiscussed, which describes the role of sitting fiberopticbronchoscopy for managing this potentially catastrophicsituation.

CASE PRESENTATIONA 41-yr-old woman with thyroid cancer was referred to a

tertiary care University hospital for her follow-up visit. Themass in her anterior neck had been diagnosed as thyroidfollicular cell carcinoma 3 yr previously, resulting in twoseparate thyroid surgeries without total eradication. Infollow-up visits, metastases to her mediastinum were de-tected. Her care was planned to include chemo-radiotherapy

with regular visits and tumor biopsies as needed.During one of the follow-up visits, she had a small

thyroid mass, with stable physical findings. After comple-tion of the physical examination, she complained of short-ness of breath, and was admitted to the hospital for observa-tion. During the ensuing several hours, the tumor enlargedacutely (Figs. 1 and 2), and her respiratory condition dete-riorated. The patient could not open her mouth, air hungerworsened, and air exchange was possible only in a sittingposition.

Immediate transfer of the patient to the operating roomoccurred with an anesthesiologist in attendance. Mean-while, an otolaryngologist and a general surgeon werepresent in the operating room and ready in case a surgicalairway was emergently needed. The patient could not liein the supine position due to air hunger. There were anumber of technical difficulties in performing the trache-ostomy due to the enlarging mass. The surgical team couldnot perform cricothyrotomy or tracheotomy under localanesthesia due to the patient’s agitation and respiratorydistress. A secure airway was needed.

Awake nasal fiberoptic intubation with the patient in thesitting-position, after surgical tracheotomy during generalanesthesia, was considered the best option. The techniqueand its underlying reasons were explained to the patient,and she was asked to be as calm and cooperative as possible.Although the patient was seated and supported by ananesthesiologist, the standard monitoring devices (electro-cardiogram, pulse oximetry, noninvasive arterial blood

pressure, and end-tidal carbon dioxide monitor) were at-tached to the patient. A nasal cannula was set in front of the

From the *Department of Anesthesiology, and †Department ofOtorhinolaryngology, Taleghani Hospital, Shahid Beheshti Univer-sity, M.C. Tehran, Iran.

Accepted for publication June 13, 2008.

Address correspondence and reprint requests to Ali Dabbagh,MD, Department of Anesthesiology and Anesthesia Research Cen-ter, Shahid Beheshti University, M.C. Tehran, Iran. Address e-mailto [email protected].

Copyright © 2008 International Anesthesia Research Society

DOI: 10.1213/ane.0b013e318184f825

Vol. 107, No. 5, November 2008 1627



patient’s teeth with an oxygen flow of 6 L per minute. Then,1.5 g/kg fentanyl and 0.5 mg atropine were injectedintravenously. The nasal passage was prepared with amixture of 2% lidocaine and 0.25% phenylephrine using 3cotton-tip applicators in different directions to achieve topi-cal anesthesia. The base of the tongue and the pharyngealwalls were anesthetized with 10% lidocaine spray (total doseof 50 mg). Topical anesthesia of the larynx and trachea wasachieved with topical lidocaine spray (total dose, 75 mg).The endotracheal tube was warmed to make it more pliableduring its nasal insertion. The lubricated endotracheal tubewas passed through the prepared nostril into the pharynx.The fiberoptic bronchoscope was passed through the endo-tracheal tube, the glottis was identified, and the fiberopticbronchoscope was advanced into the trachea. The endotra-cheal tube was advanced over the fiberoptic bronchoscopebeyond the true vocal cords, but it could not be advancedeasily beyond this point, most likely because of an extensionof the metastasis into the trachea. This assumption was latercorroborated by the anteroposterior radiograph (Fig. 3).Constant gentle pressure was exerted on the endotrachealtube until it was advanced into the trachea distal to thisstricture. At this point, auscultation of the lung fieldsrevealed bilateral air exchange. Thereafter, the patient couldlie supine on the operating table, sedated but awake. IVanesthetic induction was safely accomplished after the en-dotracheal tube was secured.

The tracheostomy was technically very difficult. Sur-geons limited their procedure to tracheostomy with no

thyroid exploration. The procedure lasted almost 2 h, with ablood loss of approximately 1000 mL. The patient made agood postoperative recovery, requiring only a 2-day stay inthe intensive care unit.

Further investigations while in the hospital revealed localbleeding and inflammatory undifferentiated thyroid carci-noma, for which she underwent thorough evaluation andtreatment.

DISCUSSION

Neck masses from different sources may affect theairway.1–8 Thyroid tumors are a potential cause fordifficult airway management. However, they rarelybecome an acute danger to the airway. Few cases ofhemorrhagic thyroid mass with resultant respiratorydistress have been reported.5,7 In this case, thyroid

manipulation during an examination caused tissuehemorrhage into the thyroid mass, which enlargedmassively in just a few hours.

Awake fiberoptic intubation remains the “goldstandard” for anticipated difficult intubation.1 Blindnasal or oral intubation is a simple technique, but it isassociated with two major drawbacks: infrequent suc-cess on the first pass, and increased trauma withrepeated attempts. We could not risk precipitatingcomplete airway obstruction that necessitated emer-gent cricothyrotomy.6 Also, insertion of the endotra-cheal tube via the nasal passage increases risk of nasal

bleeding. This can result in an inability to visualizesubsequent fiberoptic attempts due to both tissue

Figure 1. The left semilateral sitting view.

Figure 2. The right semilateral sitting view.

Figure 3. The anteroposterior radiograph taken preopera-tively: the arrow denotes the probable site of intratrachealtumor metastasis which caused a hindrance in tube passage.

1628 Case Report ANESTHESIA & ANALGESIA



edema and bleeding. Previous studies indicated fiber-optic nasotracheal intubations is associated with fre-quent failure (66% in some studies).6 However, thereare reports of a greater success rate with this proce-dure, attributed to a well-organized approach, andexpertise in flexible bronchoscopy.1,6

Avoiding airway irritation and laryngeal spasm iscritical in preventing sudden airway loss. Most authorsbelieve that using local anesthetics on the oropharyngealcavity for patient cooperation is mandatory. However,application of topical anesthesia is at times unpleasantfor the patient and may precipitate cough and laryngealspasm.6 Also, some investigators have suggested thatapplication of topical anesthesia to the oropharynx iseither not necessary during nasal intubation, or that itsefficacy is modest with some mass lesions.1–3

Tracheostomy using local anesthesia has been consid-ered the “definitive modality” of airway management insituations such as deep neck infections.6–8 Nevertheless,it may be difficult or impossible in advanced cases suchas ours because of the patient’s position needed fortracheostomy, or due to the anatomical distortion ofthe anterior neck. In our case, surgeons were reluc-tant to perform tracheostomy using local anesthesiawithout a secure airway.1,5,8

Sitting fiberoptic bronchoscopic intubation was life-saving for our patient. Therefore, we suggest thatanesthesiologists occasionally practice this techniqueso that it may be used when confronted with a patient

requiring awake urgent intubation who cannot tolerate thesupine position.

ACKNOWLEDGMENTS

The authors acknowledge the general surgery, otolaryngol-ogy, and oral and maxillofacial surgery teams, and thenursing staff of Taleghani hospital for their support andcontribution to the successful outcome of this very compli-cated patient.

REFERENCES

1. Ovassapian A. Fiberoptic Endoscopy and the Difficult Airway.2nd ed. Philadelphia: Lippincott-Raven Press, 1996

2. Belmont MJ, Wax MK, DeSouza FN. The difficult airway:cardiopulmonary bypass—the ultimate solution. Head Neck1998;20:266–9

3. Hariprasad M, Smurthwaite GJ. Management of a knowndifficult airway in a morbidly obese patient with gross supra-glottic oedema secondary to thyroid disease. Br J Anaesth2002;89:927–30

4. Huitink JM, Balm AJ, Keijzer C, Buitelaar DR. Awake fibrecapnicintubation in head and neck cancer patients with difficult air-ways: new findings and refinements to the technique. Anaesthe-sia 2007;62:214 –9

5. Oka Y, Nishijima J, Azuma T, Inada K, Miyazaki S, Nakano H,

Nishida Y, Sakata K, Hashimoto J, Izukura M. Blunt thyroidtrauma with acute hemorrhage and respiratory distress. J EmergMed 2007;32:381–5

6. Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airwaymanagement in adult patients with deep neck infections: a caseseries and review of the literature. Anesth Analg 2005;100:585–9

7. Tsilchorozidou T, Vagropoulos I, Karagianidou C, Grigoriadis N.Huge intrathyroidal hematoma causing airway obstruction: amultidisciplinary challenge. Thyroid 2006;16:795–9

8. Heidegger T, Gerig HJ. Algorithms for management of thedifficult airway. Curr Opin Anaesthesiol 2004;17:483–4

Vol. 107, No. 5, November 2008 © 2008 International Anesthesia Research Society 1629

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