BACKGROUND: Airway management of a thyroid mass in a pregnant lady

CASE REPORT: A 33-year old lady presents with a thyroid mass at 25 weeks of pregnancy. 2 FNACs performed revealed abscess contents. The mass increased in size post FNAC. MRI neck showed a 4x5cm left neck mass with tracheal displacement. She was planned for incision & drainage.

Airway examination revealed a large left neck mass, Mallampati score of 2, good thyromental distance & mouth opening, & mild decreased neck extension. She was not in respiratory distress. Examination was unremarkable apart from a gravid uterus. She was counselled for awake fibreoptic intubation (AFOI) & GA. A pre-op Doptone was performed by O&G.

She was nebulized with 5ml 2% Lignocaine & given IV Glycopyrrolate 0.2mg. Oral & nasal passages were sprayed with 3 sprays of 10% Lignocaine & Cophenylacaine. TCI Remifentanil was uptitrated to 1ng/ml. An Olympus 3.8mm fibreoptic bronchoscope was introduced via the right nostril. Aliquots of Lignocaine 2% were given above, at, & below the vocal cords via an epidural catheter as the scope was advanced. A pre-loaded size 6.5 ivory RAE tube was railroaded. Once the trachea was intubated under bronchoscopic vision & good capnography waveform was achieved, GA was induced.

Intra-op MAP was kept >70mmHg. Direct laryngoscopy (DL) performed at the end showed no airway swelling, bleeding or pus. Vocal cords were well visualized with ETT in situ. She was reversed & extubated. The right nostril was packed with Merocel due to mild bleeding. Post-op Doptone was reassuring & she was sent to high dependency. Nasal bleeding resolved by POD 2. She was discharged POD 14.

DISCUSSION/LEARNING POINTS: AFOI should be considered in patients with possible difficult airways, as in this lady who was pregnant with a large thyroid mass. AFOI can be performed nasally & orally. Nasal route is generally better tolerated & technically easier. On hindsight, we should avoid the nasal route in peripartum patients as nasal passages are engorged. It is good to perform a DL prior to extubation to exclude airway swelling/bleeding & assess visibility of cords.

In pregnancy, we should avoid teratogenic drugs which could affect development of the fetus. We should manage pain & anxiety to prevent pre-term labour. Maintenance of BP peri-operatively is also paramount to ensure adequate uterine perfusion. Consultation with O&G is essential. A multidisciplinary approach ensured a successful perioperative course for her.

10 / Awake fibreoptic intubation for drainage of a thyroid abscess in a pregnant lady.