Dr. Aishwarya Prasad, Dr Dilip chandar, Dr.N. Ramya, Dr. Udhaya Shankar


Large Retrosternal goiter is a challenge to the Anaesthesiologist and surgeon.We hereby report the successful Anaesthetic management of a 65 year old female patient with massive Retrosternal goiter with severe Intrathoracic tracheal narrowing scheduled for total Thyroidectomy.


A 65 year old femalecomplained of progressively enlarged anterior neck swelling for the past 30 years associated dyspnea on lying down and dysphagia .she was clinically and biochemically euthyroid and had no other comorbidities. On clinical examination, the Patient was found to have a right side tracheal deviation which was confirmed on chest radiograph film.the swelling was larger in size on left side of the neck, lower border of the swelling not palpable, a dull note was felt on percussion over the manubrium sternum and there was no palpable neck lymph nodes. Pemberton’s sign was negative. N o visible /engorged veins were seen on the face ,neck and chest.
Ultrasound examination of the neck showed left lobe with multiple large cystic nodules and right lobe with large colloid goiter 4*22 mm with a comet tail artifact. CT show of thyroid nodules on both sides, tracheal compression and tracheal deviation to the right.
Electrocardiography(ECG) and pulmonary function tests within the normal limits and indirect laryngoscope showed normal structure and function of the vocal cords.
The patient was reviewed by an cardiothoracic surgeon. A high risk consent was taken explaining all possible intraoperative and postoperative complications. A preoperative fasting of six hours for solid food and 2 hours of clear fluid was followed.
Patient premedicated with proton pump inhibitors and benzodiazepines day before surgery. On the day of surgery patient premedicated with intramuscular glycopyrollate 0.4 mg as an antisialagogue and nebulized with 4% lignocaine 6 ml .Superior laryngeal nerve block given with 2 % lignocaine with 3 ml on each side and 10 % lignocaine puffs given and prepared for awake flexible fiberoptic intubation .No sedative medication given.
The left radial artery cannulated under local anaesthesia and the patient was put on American society of anaesthesiologist standard monitoring. Awake FOI was perfomed and once glottic structure were identified 2 % lignocaine was sprayed directly onto the glottis inlet .tracheal intubation done with 6.5 cuffed flexometallic tube followed by administration of propofol(100 mg IV) and sevoflurane at minimum alveolar concemtration of 1.0 after intubation. Intravenous Atracurium 25 mg IV given.kocher’s collar skin crease incision was made and a midline vertical incision over the sternum.retrosternal extension was identified and excised.No intraoperative complications. Patient shifted to RICU for elective mechanical ventilation .Patient was extubated after negative cuff leak test to rule out tracheomalacia on postoperative day 1. NO postoperative complications.


A comprehensive history ,a thorough clinical examination preoperative planning and a close working relationship among multidisciplinary medical teams were prerequisite for successful delivery of anaesthesia and uneventful recovery of this patient.


– Retrosternal Goitre, Thyroidectomy, Sternotomy, Awake Fiberoptic Intubation.