surgical tracheostomy , which is a commonly performed lifesaving procedure , has a low complication rate . however , sometimes , it may become difficult as in the case of morbid obesity , any neck swelling causing displacement of the trachea or tumor invading the trachea where locating the trachea can be difficult . in such situations , fiberoptic bronchoscope may be helpful in correctly identifying the trachea thus avoiding a potential complication . the aim of this case report is to describe an effective and safe use of fiberoptic bronchoscope , aiding a difficult tracheostomy . a 50-year old male , a diagnosed case of anaplastic carcinoma of thyroid , presented with a large thyroid swelling causing respiratory distress . a decision for emergency tracheostomy was made by the surgical team and the patient was transferred to the operation theater . chest x - ray showed tracheal deviation to the right [ figure 1 ] and hopkins ( indirect laryngoscopy ) examination showed decreased right vocal cord movement . chest x - ray showing tracheal deviation the procedure was explained to the patient and informed consent was taken . intravenous access was secured and a difficult intubation trolley was kept ready in the theater with all airway adjuvants . the vocal cords were sprayed with 4% lignocaine and the airway was secured with an endotracheal tube . anesthesia was maintained with a mixture of oxygen and air with sevoflurane and intravenous drugs including fentanyl and vecuronium , which were given after confirmation of endotracheal tube in the trachea by auscultation and waveform capnography . on neck exploration the trachea that appeared to be shifted on the right side could not be seen or felt because of disease plaque . usual test of tracheal puncture , with aspiration of air through syringe , was also not helpful . therefore , it was considered unsafe to make an incision blindly on a structure that was assumed to be the trachea . to locate the trachea , a fiberoptic bronchoscope was then introduced through the endotracheal tube , which helped , as it was seen as a trans - illumination , and the tracheal position could be confirmed [ figure 2 ] . endotracheal tube was then withdrawn over the fiberoptic bronchoscope and a tracheostomy tube was introduced into the trachea . the placement of the tracheostomy tube was confirmed with waveform capnography and then the fiberoptic bronchoscope was removed . tracheal location by trans - illumination postprocedure , the neuromuscular blockade was reversed and the patient was shifted to the intensive care unit for further management . the vocal cords were sprayed with 4% lignocaine and the airway was secured with an endotracheal tube . anesthesia was maintained with a mixture of oxygen and air with sevoflurane and intravenous drugs including fentanyl and vecuronium , which were given after confirmation of endotracheal tube in the trachea by auscultation and waveform capnography . the trachea that appeared to be shifted on the right side could not be seen or felt because of disease plaque . usual test of tracheal puncture , with aspiration of air through syringe , was also not helpful . therefore , it was considered unsafe to make an incision blindly on a structure that was assumed to be the trachea . to locate the trachea , a fiberoptic bronchoscope was then introduced through the endotracheal tube , which helped , as it was seen as a trans - illumination , and the tracheal position could be confirmed [ figure 2 ] . endotracheal tube was then withdrawn over the fiberoptic bronchoscope and a tracheostomy tube was introduced into the trachea . the placement of the tracheostomy tube was confirmed with waveform capnography and then the fiberoptic bronchoscope was removed . tracheal location by trans - illumination postprocedure , the neuromuscular blockade was reversed and the patient was shifted to the intensive care unit for further management . our case is that of a patient suffering from anaplastic carcinoma of the thyroid where we used the fiberoptic bronchoscope to aid an emergency difficult tracheostomy . anaplastic thyroid ca ( atc ) is the most aggressive and lethal form of thyroid cancer . most patients with atc demonstrate local compressive symptoms such as dysphagia , dysphonia , stridor and neck pain due to direct invasion of the surrounding tissue such as fat , trachea , esophagus and larynx . airway obstruction can occur by three mechanisms : external compression of trachea , intraluminal tumor extension or bilateral vocal cord paralysis . management of atc is mostly palliative , which includes preventing death from asphyxiation and securing a safe airway . patients with stridor or rapidly growing tumor are candidates for tracheostomy , which may be challenging , and airway should first be secured in these cases under direct vision or with the use of a fiberoptic bronchoscope awake emergency tracheostomy in such patients could be tricky and can lead to life - threatening complications . our patient who was a known case of atc presented with stridor and needed an emergency tracheostomy . securing the airway was uneventful , but even in experienced hands it was difficult to locate the trachea . the fiberoptic bronchoscope that was introduced through the endotracheal tube helped in locating the trachea and to overcome the problem . this rate may increase in difficult cases like morbid obesity , cervical stiffness , tumor invading trachea or displacement of trachea . fiberoptic bronchoscope forms very important equipment for difficult intubation and has been routinely used while performing percutaneous tracheostomy . light wand - guided percutaneous tracheostomy has previously been shown to decrease complication rate and has also been useful in difficult open tracheostomy cases . we used the principle of trans - illumination to locate the trachea with a fiberoptic bronchoscope , which proved to be very useful during a difficult tracheostomy . therefore , in such cases where open tracheostomy can be challenging , we should be aware of this technique that is simple yet helpful in locating the trachea and may prove to be a good aid . this case is presented to share one of the novel applications of the fiberoptic bronchoscope in case of difficult tracheostomy .
tracheostomy can be challenging , especially in the presence of edema or infiltrative malignancy . 
 we present a case in which a fiberoptic bronchoscope that is routinely used for difficult intubation helped to locate the trachea in an emergency situation . 
 a 50 year - old male , a diagnosed case of anaplastic carcinoma of thyroid , presented with respiratory distress and was immediately taken to the operating theater for an emergency tracheostomy . following an inhalational induction , 
 the patient was intubated with an endotracheal tube . 
 surgical tracheostomy was extremely difficult as , on neck exploration , there was a plaque of disease infiltrating various tissue planes . when even after considerable dissection the trachea could not be located , we passed a fiberoptic bronchoscope through the endotracheal tube . 
 this helped as it was seen as a trans- illumination and the tracheal position could be confirmed . 
 the rest of the tracheostomy was uneventful .