Abstract
A giant retrosternal goiter can lead to compression of vital organs in the mediastinum with high risk of acute cardiorespiratory decompensation. Additionally, patients with acromegaly are prone to developing severe airway obstruction and ventilation difficulties during anesthetic induction, leading to hypoxia and an increased partial pressure of carbon dioxide. Therefore, more comprehensive airway management strategies are needed. We herein describe a 57-year-old man with acromegaly and severe tracheal obstruction caused by a giant retrosternal goiter. He presented with a 1-week history of progressive dyspnea and was scheduled to undergo right lobe thyroidectomy and retrosternal goiter thyroidectomy. We created a comprehensive emergency plan for a difficult airway, including regional and topical anesthesia for awake endotracheal intubation, sevoflurane inhalation, small doses of midazolam and sufentanil to increase tolerance, self-made extended-length tracheostomy, video laryngoscope-assisted fiber-optic bronchoscopy, extracorporeal membrane oxygenation, and surgical tracheostomy. Importantly, tetracaine was inhaled through an atomizer, and a laryngotracheal topical anesthesia applicator was used to spray the larynx with 1% tetracaine to reduce stimulation during intubation. The giant goiter was successfully removed through the cervical approach. A carefully designed airway management strategy and close communication among a multidisciplinary operation team are the basis of perioperative anesthetic management for these patients.