The Awake Tracheostomy Approach for Difficult Airway Management in a Thyroid Carcinoma Patient with Severe Tracheal Lumen Narrowing: A Case Report

Abstract

Background: Invasive thyroid carcinoma that compresses or infiltrates the trachea poses a significant challenge for anesthesiologists due to the high risk of difficult ventilation and intubation. Central airway obstruction can rapidly progress to a "cannot intubate, cannot oxygenate" (CICO) scenario upon induction of general anesthesia.

Case Presentation: We present a case of a 55-year-old female with a right T4aN1bM1 (lung) papillary thyroid carcinoma. She had a history of left isthmulobectomy and presented with a progressively enlarging neck mass, hoarseness, and stridor. Preoperative CT scan revealed a large mass destroying the cricoid cartilage and infiltrating the trachea, reducing the tracheal lumen to a critical 2.5 mm x 7.7 mm. Due to the severe airway compromise and the risk of bleeding from tumor manipulation, an awake tracheostomy under local anesthesia was performed as the definitive airway management strategy before inducing general anesthesia. The procedure was successful, and the patient underwent total thyroidectomy and right functional neck dissection.

Conclusion: In cases of severe tracheal stenosis secondary to invasive thyroid carcinoma, where conventional awake intubation techniques carry a high risk of failure or precipitating total obstruction, awake tracheostomy is a safe and reliable definitive airway management strategy.