Anesthesia Strategy in Giant Thyroid Tumor Causing Critical Tracheal Compression: Case Report

This case report presented the anesthetic management of a 53-year-old male (173 cm, 59 kg) with a giant left thyroid carcinoma causing severe tracheal compression (narrowest diameter ~4 mm) and left vocal cord paralysis, scheduled for resection. Preoperative assessment highlighted a high risk for difficult airway and major hemorrhage. Anesthesia was induced with incremental sevoflurane to preserve spontaneous ventilation and to confirm unimpeded mask ventilation, followed by rapid sequence induction and successful video laryngoscopy-guided intubation using a 6.5-mm internal diameter nerve monitoring endotracheal tube advanced to 25.5 cm to bypass the stenotic segment. Total intravenous anesthesia (TIVA) with propofol and remifentanil was maintained under BIS guidance. The 9.5-hour procedure involved significant blood loss (2800 ml), managed with invasive hemodynamic monitoring, vasopressor support (norepinephrine), transfusion of 9 units PRBCs and 800 ml FFP, and TEG-guided coagulation therapy (additional FFP and tranexamic acid) for coagulation factor deficiency and hyperfibrinolysis. Lung-protective ventilation and active thermoregulation were employed. Despite these measures, prolonged intubation contributed to postoperative pneumonia. The patient was extubated on postoperative day 3, transferred to the ward on day 5, and discharged home on day 18. This case underscores the critical importance of meticulous preoperative planning, advanced airway techniques, goal-directed hemostatic and hemodynamic management, and proactive complication prevention in complex head and neck oncologic surgery with critical airway compromise.