Background and Aim: Multinodular goiters affect 5-8% of general population, most of them being moderate in size and less than 100 grams with usual growth ratio 10-15% per year. Massive goiters (MG) weighting more than 450gram and retrosternal goiters (RSG) are exceptional but due to the anatomic location could seriously compromise the tracheal and oesophageal  patency by different ways. The aim of this study is to analyze the pitfalls during anesthesia for thyroidectomy of MG. 
Methods: a retrospective study conducted on 566 patients who underwent thyroidectomy over 2 year’s period. Anesthetic, radiological, operative and pathological data were obtained and statistically analyzed using by IBM SPSS: chi-sqare, Mann-Witney U, Fisher-exact, Student’s t-test
Results: of 566 patients, 37 cases (6,5%) were documented as having a MG, another 12 (2,1%) - as having a retrosternal goiter (RSG). All complications were observed in these too groups: symptomatic pressure/dysphagia/dyspnea/stridor (65%), Pemberton’s sign positive (9%); tracheal deviation (25,3%; mean deviation 48mm [29-58]), tracheal stenosis (1%; mean diameter reduction 46% [range 41-79%]), ease of bag ventilation (97%), difficult intubation (3%),  compression tracheomalacia (CTRM) (2,5%), tracheopexia (2,5%), postoperative reccurent laryngeal nerve (RLN) paralysis (2,5%); postoperative haemorrhage (10%). All patients underwent uneventful anesthesia and surgery under IV induction and direct laryngoscopy; by 3% of which using Airtraq. During the OP, NIM was performed (Medtronic Inc., Jacksonville, FL,USA) in all 49 pts and opioid based GA without muscle relaxants was chosen.
Discussion: Thyroid surgery poses special challenges for even a skilled anesthesiologist: management of airways, GA without muscle relaxants and postoperative complications – hemorrhage and respiratory dysfunction. Despite some very large goitres, no patient required tracheostomy or cardiopulmonary bypass and there were no perioperative deaths. We found no good evidence that thyroid surgery patients with retrosternal goiter, with or without symptoms and signs of tracheal compression, present the experienced anesthetists with an airway that cannot be managed using conventional techniques.  
Conclusion: Serious complications can occur in patients with MG or RSG concerning patency of airways pre/postoperatively. For risk management we would still advocate that such patients be managed in units where multidisciplinary teams are available. 
Learning points: patency and management of airways, free of muscle relaxants general anesthesia and postoperative haemorrhage are although rare, but real pitfalls even for skilled anesthesiologists during thyroidectomy surgery for MG.
	
	References: 
Gilfillan N, Ball CM, Myles PS and al. A cohort and database study of airway management in patients undergoing thyroidectomy for retrosternal goiter. Anesth Int Care 2014: 4:700-708
Norman Oneil Machado. Thyroidectomy for Massive goiter weighing more than 500gr. Surgical Science, 2011, 2, 278-284
Rifat Lafifi, Joan Harper, Renato Rivera. Total thyroidectomy for giant goiter under local anesthesia and Ketamine in a surgical mission. Int J Surg Case rep. 2015;8:52-54
Findley M, Sadler G, Bridge G, Mihai R. Post-tyroidectomy tracheomalacia: minimal risk despite significant tracheal compression. Br G of Anesth. doi:10.1093/bja/aer062

Pitfalls during anesthesia for thyroidectomy of massive goiter