RT Book, Section A1 Zhang, Jinbin A1 Seet, Edwin A1 Hung, Orlando R. A2 Hung, Orlando R. A2 Murphy, Michael F. SR Print(0) ID 1202477978 T1 Management of a Patient with OSA and Retrosternal Multinodular Goiter, Presenting for Total Thyroidectomy T2 Hung’s Management of the Difficult and Failed Airway, 4th Edition YR 2024 FD 2024 PB McGraw Hill PP New York, NY SN 9781264278329 LK accessanesthesiology.mhmedical.com/content.aspx?aid=1202477978 RD 2024/09/18 AB A 55-year-old female with a BMI of 36 kg∙m−2 presented for total thyroidectomy for a long-standing multinodular goiter. She appeared clinically euthyroid and her thyroid function tests were normal. Although retrosternal extension, mid-tracheal deviation, and compression were demonstrated on the CT scan (Figure 43.1), the patient did not exhibit any compressive symptoms. On preoperative screening using the STOP-Bang questionnaire, the patient was deemed to be at high risk for OSA in view of the presence of loud snoring, daytime sleepiness, history of hypertension, BMI greater than 35 kg∙m−2, and age above 50 years old. She offered the information that she was told “it was difficult to insert a breathing tube” during her previous surgery 10 years ago, but could not recall further details. Airway examination demonstrated mouth opening >5 cm, a short neck but good cervical extension (flexion was limited by the large goiter), Mallampati class IV, large tongue, and thyromental distance of 4 cm. Referral to a sleep physician for sleep study evaluation was offered but the patient declined due to financial reasons. She also adamantly refused awake intubation despite a thorough explanation of the indications. After discussion with the surgeon and patient, the plan was to proceed with the surgery with risk-mitigating strategies in view of patient’s refusal for further investigations.