CASE REPORT

Preanesthesia concerns in a patient with a

thyroid mass
Gayle B. Bodner, MMS, PA-C; Ashley L. Talbott, MD

ABSTRACT
Preoperative evaluation helps identify patient comorbidi-
ties and surgical characteristics that increase perioperative
risk, and also can help identify patients with potentially
difficult airways. Identifying patients with difficult airways
before surgery lets clinicians plan appropriate perioperative
management and prepare for potential complications. This
article focuses on management of a difficult airway in a
patient undergoing surgery for a thyroid mass.
Keywords: difficult airway, preoperative evaluation, periop-
erative management, thyroid mass, surgery, assessment

CASE
A 47-year-old woman presented to the preoperative assess-
ment clinic for evaluation before a semielective total thy-
roidectomy. She presented to the surgeon’s office with a
1-year history of enlarged neck, throat pain, dyspnea, and
dysphagia but denied anxiousness, changes in weight, or
significant fatigue. For the past few weeks, she has slept with
her head tilted to the left and has had trouble staying asleep.
History Four years ago, a thyroid lesion biopsy showed a
benign follicular nodule of the left lobe. She denied any his-
tory of head or neck radiation. She has no family history of
thyroid disease nor history of adverse reaction to anesthesia.
The patient’s past medical history is remarkable for
chronic hypoxia secondary to obesity-hypoventilation
syndrome. She is on 4 L of supplemental oxygen at night
and daily as needed. Her pulmonary medications include
fluticasone propionate and salmeterol inhaler twice daily
and albuterol via metered-dose inhaler and/or nebulizer a
few times per day. Her history also is notable for moderate
pulmonary hypertension by echo criteria, very severe
obstructive sleep apnea (OSA) requiring bi-level positive
airway pressure (BiPAP) ventilation, anemia secondary to
menorrhagia, and morbid obesity.
Physical examination The patient appeared mildly drowsy
but was easily arousable, alert, and oriented. Her vital
Gayle B. Bodner and Ashley L. Talbott practice in the Department of
Anesthesiology at Wake Forest University Baptist Medical Center in
Winston-Salem, N.C. The authors have disclosed no potential conflicts
of interest, financial or otherwise.
DOI: 10.1097/01.JAA.0000530292.13871.20
Copyright © 2018 American Academy of Physician Assistants
FIGURE 1. CT scan of neck showing narrowing and rightward
deviation of the trachea (arrow)
signs were: BP, 131/60 mm Hg; pulse, 88; and Spo2, 95%
on room air. She was 5’2” (157.5 cm) tall and weighed
295 lbs (133.8 kg), for a body mass index (BMI) of 54.1.
An airway examination revealed native dentition, oral
aperture of 3 ordinary fingerbreadths, modified Mal-
lampati classification of III (only the soft palate visible),
and thyromental distance of 2 fingerbreadths. The
patient’s neck was thick with an obvious right neck mass.
Lung examination revealed breath sounds clear to aus-
cultation bilaterally without wheezing. Cardiovascular
examination revealed distant heart sounds but regular
rate and rhythm. Neurologic examination revealed no
focal deficits. The patient’s skin was warm and dry with
trace ankle edema. She had normal affect, behavior, and
thought content.
Diagnostic testing Laboratory studies including complete
blood cell (CBC) count, basic metabolic panel, thyroid-
stimulating hormone, and free thyroxine were within
normal limits except for a hemoglobin of 8.4 g/dL, hema-
tocrit of 29.5%, mean corpuscular volume of 66 fL, and
mean corpuscular hemoglobin of 18.7 pg. Pulmonary

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CASE REPORT
Key points
Preoperative evaluation can help identify patients with
potentially difficult airways.
The evaluation also can address anesthesia tolerance
before elective surgery and attempt to minimize
perioperative risk.
Educating patients about the perioperative process and
anesthesia plan can alleviate patient anxiety.
function testing had previously shown moderate restriction,
likely secondary to morbid obesity.
A preoperative CT scan of the patient’s neck showed a
well-circumscribed enlarged thyroid gland (right lobe more
so than left) without evidence of adjacent bony or carti-
laginous erosion. Inferior substernal extension and superior
extension up to the level of C2 to C3 were noted. Mass
effect from the enlarged thyroid gland resulted in narrow-
ing and rightward deviation of the trachea and anatomic
distortion of the larynx (Figure 1).
A transthoracic echocardiogram from 2 years ago showed
normal left ventricular (LV) function with an ejection frac-
tion of 50% to 55%, mild concentric LV hypertrophy, and
normal LV wall motion. The right ventricle was not well
visualized. The patient was noted to have moderate pul-
monary hypertension with a right ventricular systolic
pressure of 51 to 60 mm Hg. A 12-lead ECG showed
normal sinus rhythm at 92 beats/minute.
Multiple perioperative concerns for this patient were
identified in the preoperative assessment clinic, including
potentially difficult bag-mask ventilation, possible difficult
endotracheal intubation or inability to extubate and need
for postoperative ventilation, moderate pulmonary hyper-
tension, decompensated heart failure, and high risk for
postoperative pulmonary complications.
Due to the patient’s obstructive symptoms from the thyroid
mass, delaying surgery was not considered beneficial. In the
context of dyspnea and noted pulmonary hypertension, a
preoperative echocardiogram was ordered for reevaluation.
This study was otherwise unchanged with the exception
that the right ventricular systolic pressure improved to 36
mm Hg, which was attributed to better BiPAP compliance.
An anesthesia plan was reviewed at length with the patient
including arterial line placement and overview of fiberop-
tic intubation with airway blocks. Risks, including post-
operative ventilation, pulmonary infection, and
decompensated heart failure, also were discussed. The
patient was typed and crossmatched for 2 units of blood
due to the potential for her hemoglobin to fall below 8 g/
dL with poor oxygen-carrying capacity. She was to continue
iron supplementation for her anemia until surgery. The
concerns about her difficult airway were documented in
the preoperative anesthesia evaluation note.
On the day of surgery, the patient presented without her
supplemental oxygen and with an Spo2 of 54% on room
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air. Her oxygenation rapidly improved with 4 L/min of
supplemental oxygen via nasal cannula. The decision was
made to proceed with surgery as the compressive nature of
her thyroid mass was thought to be a significant contribut-
ing factor to her chronic hypoxemia. Preparation for awake
fiberoptic intubation began with 4% lidocaine nebulizer
administered to the patient in the preoperative holding
room. Despite her distorted neck anatomy and morbid
obesity, cartilaginous landmarks for airway blocks were
easily palpated. After minimal IV sedation titrated to effect,
bilateral superior laryngeal nerve blocks, glossopharyngeal
blocks, and recurrent laryngeal nerve block were success-
fully performed in the OR. Gag reflex was tested and suc-
cessfully ablated. A 5.7 fiberoptic scope was advanced into
the oropharynx, the glottis was visualized and a 7.0 endo-
tracheal (ET) tube was deployed over the scope and secured
after confirmation of equal bilateral breath sounds and
positive end-tidal carbon dioxide (Etco2). General anesthe-
sia was then induced with propofol and maintained with
isoflurane. The operator noted significant redundant soft
tissue and laryngeal distortion with fiberoptic bronchoscopy.
An arterial line was placed and arterial blood gas values
showed pH of 7.424, Paco2 of 49 mm Hg, Pao2 of 110.3
mm Hg, bicarbonate of 31.4 mmol/L, and Sao2 of 98.4%.
Her base excess was 6.2 mmol/L.
About 2 hours into surgery, acute loss of Etco2 with
increase in peak airway pressures and acute desaturation
to 60s were noted. After immediate notification, the surgeon
released significant traction on the trachea. Etco2 returned,
but peak airway pressures remained high. Hypoxemia
improved with manual ventilation and 100% oxygen.
Breath sounds were noted to be decreased on the left lead-
ing to concern for right mainstem intubation caused by
surgical manipulation of the trachea. The ET tube was
retracted to about 23 cm at the teeth with improvement
in positive inspiratory pressure to baseline. Her vital signs
remained stable throughout. The anesthesiologist and
surgeon discussed the patient’s chronic anemia and chronic
hypoxic respiratory failure. Due to her significant existing
comorbidities (pulmonary hypertension, severe OSA, and
morbid obesity), discussion included benefit derived from
the increased oxygen carrying capacity related to transfu-
sion of packed red blood cells (PRBCs), with a goal hemo-
globin greater than 8 g/dL. The patient was transfused
1 unit of PRBCs and reassessed. The remainder of the case
was unremarkable. The initial plan included possibility of
postoperative ventilation given concern for airway com-
promise (surgical complications, difficulty with ventilation,
difficult intubation); however, the patient met all extubation
criteria at the end of the procedure. She was successfully
extubated fully awake, followed commands, and breathed
spontaneously with adequate tidal volumes and a regular
respiratory pattern. She was placed directly on continuous
positive airway pressure (CPAP) via nasal trumpet and
transferred to the postanesthesia care unit, where she
Volume 31 • Number 3 • March 2018

TABLE 1. ASA physical status classification system
An E is added to the classification for emergencies, defined
as when delaying surgery would lead to a significant
increase in the threat to life or body part.
• ASA I—a normal healthy patient
• ASA II—a patient with mild systemic disease. Examples:
current smoking, pregnancy, obesity (BMI greater than 30
but less than 40), well-controlled diabetes or hypertension
• ASA III—a patient with severe systemic disease.
Examples: morbid obesity (BMI greater than 40), poorly
controlled diabetes or hypertension, active hepatitis,
implanted pacemaker, history (more than 3 months) of
myocardial infarction (MI) or stroke
• ASA IV—a patient with severe systemic disease that is
a threat to life. Examples: recent (less than 3 months)
history of MI or stroke, severe cardiac valve dysfunction,
sepsis, end-stage renal disease without regular dialysis
• ASA V—a moribund patient who is not expected to survive
without the operation. Examples: ruptured abdominal or
thoracic aneurysm, massive trauma, intracranial bleeding
with mass effect, multiple organ system dysfunction
• ASA VI—a patient declared brain-dead whose organs are
being removed for donation
recovered uneventfully. The patient was admitted overnight
to the ICU for close monitoring of her respiratory status
and to allow for rapid intervention if she developed airway
edema or hypoventilation. She recovered without incident
and was discharged the next day.
DISCUSSION
Preoperative evaluation is performed to address anesthesia
tolerance prior to elective surgery as well as attempt to
minimize perioperative risk. All surgical patients must
undergo preoperative evaluation by their anesthesia pro-
vider. It is the obligation of the healthcare system to, at a
minimum, provide pertinent information to the anesthe-
siologist for the assessment of the severity of the patient’s
medical condition and invasiveness of the surgical procedure
well in advance of the anticipated day of elective procedure.1
This process has evolved over time and hospitals have
developed anesthesia-led or medicine-led outpatient pre-
operative evaluation clinics.2 The essential evaluation
performed in these clinics includes obtaining important
patient history, focused physical examination, reviewing
pertinent diagnostics, and evaluating perioperative risk.
Secondly, it is an opportunity to optimize preexisting
conditions through interventions and referrals or consider
alternative options for nonsurgical approaches, when
appropriate, in high-risk patients. During this visit, another
goal for the provider should be to facilitate conversation
in an attempt to reduce anxiety through understanding of
the perioperative journey for the patient and family.
Postoperative pulmonary complications are common.
Many patient and surgical characteristics have been shown
to increase risk, including older age, American Society of
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2018 American Academy of Physician Assistants
Preanesthesia concerns in a patient with a thyroid mass
Anesthesiologists (ASA) physical status classification of 2
or greater (Table 1), heart failure, functional dependence,
and chronic obstructive pulmonary disease. However,
surgical site was the most predictive and included surger-
ies of the thorax, abdomen, head and neck, and vasculature
as well as neurosurgery, prolonged surgery, emergency
surgery, and use of general anesthesia.3
A history of OSA is important to recognize. Mask ven-
tilation, direct laryngoscopy, ET intubation, and fiberoptic
visualization of the airway are more challenging in patients
with OSA. These patients are likely to have perioperative
airway obstruction, hypoxemia, atelectasis, ischemia,
pneumonia, and prolonged hospitalizations.4 Patients with
OSA are more sensitive to the respiratory depressant effects
of opioids, sedatives, and inhaled anesthetics.5
For patients with an anticipated difficult airway, failure to
maintain the airway can have serious outcomes, including
death, anoxic brain injury, cardiopulmonary arrest, unneces-
sary surgical airway, airway trauma, and damage to the teeth.6
CONCLUSION
In this patient, evaluation in the preoperative assessment
clinic lets the healthcare team identify potential difficulties
with bag-mask ventilation (increased BMI, OSA), ET
intubation (deviated trachea, obesity, OSA), concerns for
extubation (chronic hypoxemia, OSA), and higher risk of
postoperative pulmonary complications (neck surgery, ASA
greater than 2, surgery length greater than 2 hours, planned
general anesthesia). This allowed for informed consent and
patient education before surgery. Additionally, the team
was able to update the patient’s transthoracic echocardio-
gram to evaluate one of her many comorbidities. Evaluation
allowed for planning and execution of fiberoptic intubation
and safe maintenance of general anesthesia, airway control,
ventilation, and postoperative recovery. JAAPA
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