PMC5960512_01
Preoperative CT scan. (a) Lateral curvature of the spine. (b) Narrowest portion of the trachea was 4 mm in diameter in lying down.
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fig1
He had skeletal abnormalities including craniofacial deformities, short neck, enlarged and greatly deformed thorax, scoliosis, and kyphosis (Figure 1(a)). The narrow portion extended over a length of about 20 mm (4 slices at 5 mm width) (Figure 1(b)).
Preoperative lateral neck X-ray with the head resting on the bed in a neutral position. X-ray shows short neck with limited extension. The glottis is elevated by the dorsally located goitre. OA: oral axis, PA: pharyngeal axis, TA: tracheal axis, and GPA: glottis- pharyngeal axis.
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The oral, pharyngeal, and tracheal axes were measured (Figure 2).
Straight type without diagonal tip. The Ruschelit tube has an obtuse-angled tip; the Safety-Flex Reinforced tube has a slanted tip.
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fig3
I attempted nasotracheal fiberoptic intubation with a standard endotracheal tube (Lo-counter  Muphy Tracheal Tube Mallinckrodt, 5.5 mm internal diameter (ID)) and a spiral-wound tube (Safety-Flex  Reinforced Tracheal Tube Mallinckrodt, 5.5 mm ID) (Figure 3). Tube, 5.5 mm ID) with an obtuse-angled tip (Figure 3).
Preoperative laryngeal fibroscopy showing the trachea shifted to the right, and the posterior pharyngeal wall and glottis were pushed forward.
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Even though I were able to introduce the fiberscope into the trachea, I were unable to perform tracheal intubation as I could not pass the tip of the endotracheal tube beyond the arytenoids (Figure 4).
Anaesthetic chart of patient undergoing thyroidectomy. x: induction, #: intubation, and O: start of operation.
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fig5
The slight rightwards shifts of the trachea by the goitre did not increase the difficulty of intubation using the fiberoptic laryngoscope. The tumour was soft and permitted easy placement of the tracheal tube. The total anaesthetic time was 8 hours 32 minutes, with 33 minutes' tracheal intubation from induction of anaesthesia and 6-hour 49-minute operation (Figure 5).
The extirpated tumour (515 g, 15 cm x 13 cm).
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The extirpated tumour weighed 515 g and measured 15 cm x 13 cm (Figure 6).