6% of reported cases [44]. However, when the extension of the goiter is retroclavicular, it can cause airway obstruction that may progress to arrest respiration [2, 45, 46]. Nevertheless, in the presence of benign thyroid disease, chronic obstructive airways disease, substernal extension, and long-standing goiter are considered as risk factors for developing acute, life-threatening

airway compromission [44]. It is clear that the appearance of an acute airway obstruction requires urgent management to ensure an adequate ventilation and oxygenation. EPZ5676 in vivo The first step in the management of this emergency is represented by the anesthesia. An awake fiberoptic intubation using a small endotracheal tube followed by induction of general anesthesia, as

always performed in this reported series, seem to be the gold standard in the approach to this emergency. Indeed, check details a standard sequence of induction and intubation could be considered at risk of aspiration in an unfasted patient, and besides this, the possibility of unsuccessful intubation due to the compression by the goiter is very high. On the other hand, an inhalation induction followed by laringoscopy and orotracheal or blind nasal intubations, may be considered dangerous because of complete airway obstruction following loss of consciousness [47, 48]. When assisted intubation cannot be achieved, local or regional anesthesia are described too [21]. The second step is the choice of surgical treatment to be performed. Indeed, surgery – emergency or early – is always indicated for severe airway obstruction caused by thyroid mass [23]. An emergency tracheostomy is hindered by the presence of the thyroid mass which prevents access to the trachea, obliterating all landmarks [21]. An isthmectomy to allow a tracheostomy, appears to be an incomplete treatment, referring to Thymidine kinase a second surgical procedure for removing the entire thyroid. Moreover, in the presence of diagnosis

of proven or suspected malignancy, it would cause a further delay in cancer treatment and exposes the patient to the risk of tumor dissemination. However, even in the presence of a benign goiter, re-surgery would mean higher morbidity [49, 50]. Finally, once an endotracheal intubation has been performed, tracheotomy is questionable. Since a total thyroidectomy is capable of resolving airway obstruction, tracheostomy would result in unnecessary discomfort for the patient, furthermore exposing then to the need of a second operation to close the stomy. In our experience tracheostomy was necessary in only one case (16.7%) due to the evidence of a marked tracheomalacia. Then, total, near-total or sub-total thyroidectomy represents the treatment of choice of acute airway obstruction resulting from compression of thyroid mass.