Large goitre causing difficult intubation and failure to intubate using the intubating laryngeal mask airway: lessons for next time

A 63-yr-old woman was anaesthetized for sub-total thyroidectomy. Thethyroid gland was large, deviating the trachea to the right and causing 30%tracheal narrowing at the level of the suprasternal notch. Mask ventilationwas easy but laryngoscopy was Cormack and Lehane grade 3. Despite beingable to see the tip of the epiglottis, tracheal intubation was impossible.An intubating laryngeal mask was inserted and although the airway was clearand ventilation easy, it was not possible to intubate the trachea eitherblindly or with the fibreoptic bronchoscope. Tracheal intubation waseventually achieved using a 6.5- mm cuffed oral tracheal tube via a size 4laryngeal mask under fibreoptic control. We describe the case in detail anddiscuss the use of the intubating laryngeal mask, its potential limitationsand how to optimize its use in similar circumstances.