Case Report

A Rapidly Enlarging Neck Mass: The Role of the

Sitting Position in Fiberoptic Bronchoscopy for
Difficult Intubation
Ali Dabbagh, MD*
Naseraddin Mobasseri, MD*
Hedayatollah Elyasi, MD*
Babak Gharaei, MD*
Mohammadreza Fathololumi,
MD†
Difficult airway management is a dilemma for any anesthesiologist. Although
practice guidelines and algorithms may help in such situations, the anesthesi-
ologist’s judgment and vigilance remain the primary means to save lives. In the
following case, we encountered an acutely enlarging thyroid mass that was
compromising the airway. This huge neck mass precluded tracheostomy under
local anesthesia, and the patient could breathe only in the sitting position.
Therefore, there were few safe strategies for airway management for general
anesthesia. We reiterate the role of awake fiberoptic intubation in such
circumstances.
(Anesth Analg 2008;107:1627–9)

Mahshid Ghasemi, MD*

Iman Bandarchi Chamkhale, MD*

M anagement of the difficult airway presents a

great dilemma for the anesthesiologist. Practice
guidelines and algorithms may help in such situa-
tions. However, the anesthesiologist’s judgment and
vigilance remain the primary means to safe airway
management. Neck masses from different sources
may 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 enlarging
and airway-compromising anterior neck mass, such
as thyroid tumors. These patients may not tolerate the
supine position due to stridor and tracheal compres-
sion. The utility and safety of performing tracheos-
tomy in the awake patient prior to induction of
general anesthesia are debatable, due to the location of
the mass and the displaced anatomy it produces.
Awake fiberoptic intubation remains a safe and
effective method in experienced hands. A case of
difficult intubation due to an enlarging neck mass is
discussed, which describes the role of sitting fiberoptic
bronchoscopy for managing this potentially catastrophic
situation.
From the *Department of Anesthesiology, and †Department of
Otorhinolaryngology, 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-mail
to alidabbagh@yahoo.com.
Copyright © 2008 International Anesthesia Research Society
DOI: 10.1213/ane.0b013e318184f825
CASE PRESENTATION
A 41-yr-old woman with thyroid cancer was referred to a
tertiary care University hospital for her follow-up visit. The
mass in her anterior neck had been diagnosed as thyroid
follicular cell carcinoma 3 yr previously, resulting in two
separate thyroid surgeries without total eradication. In
follow-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 enlarged
acutely (Figs. 1 and 2), and her respiratory condition dete-
riorated. The patient could not open her mouth, air hunger
worsened, and air exchange was possible only in a sitting
position.
Immediate transfer of the patient to the operating room
occurred with an anesthesiologist in attendance. Mean-
while, an otolaryngologist and a general surgeon were
present in the operating room and ready in case a surgical
airway was emergently needed. The patient could not lie
in the supine position due to air hunger. There were a
number of technical difficulties in performing the trache-
ostomy due to the enlarging mass. The surgical team could
not perform cricothyrotomy or tracheotomy under local
anesthesia due to the patient’s agitation and respiratory
distress. A secure airway was needed.
Awake nasal fiberoptic intubation with the patient in the
sitting-position, after surgical tracheotomy during general
anesthesia, was considered the best option. The technique
and 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 an
anesthesiologist, 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

Vol. 107, No. 5, November 2008 1627

Figure 1. The left semilateral sitting view.
Figure 2. The right semilateral sitting view.
patient’s teeth with an oxygen flow of 6 L per minute. Then,
1.5 ␮g/kg fentanyl and 0.5 mg atropine were injected
intravenously. The nasal passage was prepared with a
mixture of 2% lidocaine and 0.25% phenylephrine using 3
cotton-tip applicators in different directions to achieve topi-
cal anesthesia. The base of the tongue and the pharyngeal
walls were anesthetized with 10% lidocaine spray (total dose
of 50 mg). Topical anesthesia of the larynx and trachea was
achieved with topical lidocaine spray (total dose, 75 mg).
The endotracheal tube was warmed to make it more pliable
during its nasal insertion. The lubricated endotracheal tube
was passed through the prepared nostril into the pharynx.
The fiberoptic bronchoscope was passed through the endo-
tracheal tube, the glottis was identified, and the fiberoptic
bronchoscope was advanced into the trachea. The endotra-
cheal tube was advanced over the fiberoptic bronchoscope
beyond the true vocal cords, but it could not be advanced
easily beyond this point, most likely because of an extension
of the metastasis into the trachea. This assumption was later
corroborated by the anteroposterior radiograph (Fig. 3).
Constant gentle pressure was exerted on the endotracheal
tube until it was advanced into the trachea distal to this
stricture. At this point, auscultation of the lung fields
revealed bilateral air exchange. Thereafter, the patient could
lie supine on the operating table, sedated but awake. IV
anesthetic 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
1628 Case Report
Figure 3. The anteroposterior radiograph taken preopera-
tively: the arrow denotes the probable site of intratracheal
tumor metastasis which caused a hindrance in tube passage.
thyroid exploration. The procedure lasted almost 2 h, with a
blood loss of approximately 1000 mL. The patient made a
good postoperative recovery, requiring only a 2-day stay in
the intensive care unit.
Further investigations while in the hospital revealed local
bleeding and inflammatory undifferentiated thyroid carci-
noma, for which she underwent thorough evaluation and
treatment.
DISCUSSION
Neck masses from different sources may affect the
airway.1– 8 Thyroid tumors are a potential cause for
difficult airway management. However, they rarely
become an acute danger to the airway. Few cases of
hemorrhagic thyroid mass with resultant respiratory
distress have been reported.5,7 In this case, thyroid
manipulation during an examination caused tissue
hemorrhage into the thyroid mass, which enlarged
massively in just a few hours.
Awake fiberoptic intubation remains the “gold
standard” for anticipated difficult intubation.1 Blind
nasal or oral intubation is a simple technique, but it is
associated with two major drawbacks: infrequent suc-
cess on the first pass, and increased trauma with
repeated attempts. We could not risk precipitating
complete 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 visualize
subsequent fiberoptic attempts due to both tissue
ANESTHESIA & ANALGESIA
edema and bleeding. Previous studies indicated fiber-
optic nasotracheal intubations is associated with fre-
quent failure (66% in some studies).6 However, there
are reports of a greater success rate with this proce-
dure, attributed to a well-organized approach, and
expertise in flexible bronchoscopy.1,6
Avoiding airway irritation and laryngeal spasm is
critical in preventing sudden airway loss. Most authors
believe that using local anesthetics on the oropharyngeal
cavity for patient cooperation is mandatory. However,
application of topical anesthesia is at times unpleasant
for the patient and may precipitate cough and laryngeal
spasm.6 Also, some investigators have suggested that
application of topical anesthesia to the oropharynx is
either not necessary during nasal intubation, or that its
efficacy is modest with some mass lesions.1–3
Tracheostomy using local anesthesia has been consid-
ered the “definitive modality” of airway management in
situations such as deep neck infections.6 – 8 Nevertheless,
it may be difficult or impossible in advanced cases such
as ours because of the patient’s position needed for
tracheostomy, or due to the anatomical distortion of
the anterior neck. In our case, surgeons were reluc-
tant to perform tracheostomy using local anesthesia
without a secure airway.1,5,8
Sitting fiberoptic bronchoscopic intubation was life-
saving for our patient. Therefore, we suggest that
anesthesiologists occasionally practice this technique
so that it may be used when confronted with a patient
Vol. 107, No. 5, November 2008
requiring awake urgent intubation who cannot tolerate the
supine position.
ACKNOWLEDGMENTS
The authors acknowledge the general surgery, otolaryngol-
ogy, and oral and maxillofacial surgery teams, and the
nursing staff of Taleghani hospital for their support and
contribution to the successful outcome of this very compli-
cated patient.
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© 2008 International Anesthesia Research Society 1629