J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://jmc.elmerpub.com

Case Report

Volume 17, Number 12, December 2026, pages 712-726

First-Attempt Video Laryngoscopic Intubation in an Adult With Down Syndrome and Severe Tracheal Compression From a Giant Retrosternal Goiter

↓ Figure 1. Preoperative imaging demonstrating extensive retrosternal extension of a multinodular goiter. (a–c) Coronal contrast-enhanced CT images demonstrating a markedly enlarged multinodular thyroid gland with substantial retrosternal extension into the superior mediastinum (red arrows), causing narrowing and displacement of the trachea. (d) Preoperative chest radiograph demonstrating widening of the superior mediastinum with rightward tracheal deviation (red arrow), consistent with the retrosternal extension of the goiter. CT: computed tomography.

↓ Figure 2. Contrast-enhanced CT demonstrating giant retrosternal goiter with tracheal compression and deviation. (a) Coronal CT images demonstrating the longitudinal extent of the tracheal stenosis, measuring approximately 10 mm in length. (b) Sagittal CT images demonstrating the longitudinal extent of the tracheal stenosis, measuring approximately 10 mm in length. (c) Axial chest CT image demonstrating severe narrowing of the tracheal lumen, most pronounced at the proximal tracheal segment. (d) Coronal CT image demonstrating the distance between the proximal margin of the tracheal stenosis and the tracheal bifurcation (carina), measuring approximately 60 mm. CT: computed tomography.

↓ Figure 3. Sequential video laryngoscopy views during airway management in our patient with a large retrosternal goiter. (a) Initial video laryngoscopy view demonstrating Cormack–Lehane grade 1. (b) Video laryngoscopy view during advancement of the endotracheal tube toward the glottic opening, demonstrating the tube approaching the vocal cords under direct video guidance. (c) Improved visualization of the glottis with clear identification of the vocal cords, facilitating controlled endotracheal intubation.

↓ Figure 4. Intraoperative processed EEG monitoring during general anesthesia: SedLine display showing bilateral density spectral array (DSA) trends and processed EEG monitoring, with a PSI of 26, demonstrating continued adequate anesthesia depth and bilateral cerebral electrical activity. EEG: electroencephalography; PSI: patient state index.

↓ Figure 5. Perioperative airway features and surgical findings. (a) Patient intubated and positioned for surgery, demonstrating marked anterior neck enlargement caused by the giant goiter. (b) Macroglossia identified during airway assessment, representing an additional anatomical challenge for airway management. (c) Surgical field following thyroid gland removal and sternotomy, demonstrating the operative site after resection of the retrosternal goiter. (d, e) Macroscopic views of the resected thyroid specimen, demonstrating its large size and multinodular appearance.

↓ **Table 1.** Comprehensive Preoperative Assessment of Our Patient With Down Syndrome and Giant Retrosternal Goiter
Parameter	Value	Normal limits/interpretation
Anti-TPO: anti-thyroid peroxidase antibody; Anti-Tg: anti-thyroglobulin antibody; TSH: thyroid-stimulating hormone; FT4: free thyroxine; 25-OH vitamin D₃: 25-hydroxyvitamin D₃; PTH: parathyroid hormone; LVEF: left ventricular ejection fraction; PASP: pulmonary artery systolic pressure; OSA: obstructive sleep apnea; STOP-BANG: Snoring, Tiredness, Observed apnea, high blood Pressure, BMI, Age, Neck circumference, and Gender; BMI: body mass index; SVC: superior vena cava; CT: computed tomography; FNA: fine-needle aspiration; ECG: electrocardiogram, bpm: beats per minute.
Anti-TPO	15.2 IU/mL	< 34 IU/mL; negative
Anti-TG	25 IU/mL	< 115 IU/mL; negative
Thyroglobulin	473 ng/mL	< 77 ng/mL; elevated
23-OH-vitamin D₃	53.44 ng/mL	30–100 ng/mL; normal
TSH	1.37 µIU/mL	0.27–4.2 µIU/mL; normal
FT4	1.4 ng/dL	0.93–1.7 ng/dL; normal
Calcium (total)	8.4 mg/dL	8.4–10.2 mg/dL; low-normal
Calcium (ionized)	1.30 mmol/L	1.13–1.32 mmol/L; normal
PTH	37.5 pg/mL	15–65 pg/mL; normal
Albumin	3.8 g/dL	3.5–5.2 g/dL; normal
Echocardiography	LVEF 62%; no right-sided dilatation; estimated PASP 31 mm Hg, ECG 71 bpm sinus rhythm	Preserved LV systolic function; no evidence of pulmonary hypertension
OSA	STOP-BANG 3 points (BMI, increased neck circumference, snoring)	Intermediate risk for OSA
Great vessels compression	No clinical or CT evidence	No evidence of great-vessel or SVC compression
Thyroid ultrasound	Multinodular goiter	Structural thyroid abnormality
Preoperative FNA	Not performed; relatives declined the procedure	No preoperative cytological/Bethesda classification available

↓ Table 1. Comprehensive Preoperative Assessment of Our Patient With Down Syndrome and Giant Retrosternal Goiter

Parameter

Value

Normal limits/interpretation

Anti-TPO: anti-thyroid peroxidase antibody; Anti-Tg: anti-thyroglobulin antibody; TSH: thyroid-stimulating hormone; FT4: free thyroxine; 25-OH vitamin D₃: 25-hydroxyvitamin D₃; PTH: parathyroid hormone; LVEF: left ventricular ejection fraction; PASP: pulmonary artery systolic pressure; OSA: obstructive sleep apnea; STOP-BANG: Snoring, Tiredness, Observed apnea, high blood Pressure, BMI, Age, Neck circumference, and Gender; BMI: body mass index; SVC: superior vena cava; CT: computed tomography; FNA: fine-needle aspiration; ECG: electrocardiogram, bpm: beats per minute.

Anti-TPO

15.2 IU/mL

< 34 IU/mL; negative

Anti-TG

25 IU/mL

< 115 IU/mL; negative

Thyroglobulin

473 ng/mL

< 77 ng/mL; elevated

23-OH-vitamin D₃

53.44 ng/mL

30–100 ng/mL; normal

TSH

1.37 µIU/mL

0.27–4.2 µIU/mL; normal

FT4

1.4 ng/dL

0.93–1.7 ng/dL; normal

Calcium (total)

8.4 mg/dL

8.4–10.2 mg/dL; low-normal

Calcium (ionized)

1.30 mmol/L

1.13–1.32 mmol/L; normal

PTH

37.5 pg/mL

15–65 pg/mL; normal

Albumin

3.8 g/dL

3.5–5.2 g/dL; normal

Echocardiography

LVEF 62%; no right-sided dilatation; estimated PASP 31 mm Hg, ECG 71 bpm sinus rhythm

Preserved LV systolic function; no evidence of pulmonary hypertension

OSA

STOP-BANG 3 points (BMI, increased neck circumference, snoring)

Intermediate risk for OSA

Great vessels compression

No clinical or CT evidence

No evidence of great-vessel or SVC compression

Thyroid ultrasound

Multinodular goiter

Structural thyroid abnormality

Preoperative FNA

Not performed; relatives declined the procedure

No preoperative cytological/Bethesda classification available

↓ **Table 2.** Timeline of the Patient’s Clinical Presentation, Diagnostic Assessment, Airway Management, Surgery, and Postoperative Course
Time	Clinical event
BiPAP: bilevel positive airway pressure; PEEP: positive end-expiratory pressure.
18 months before surgery	Progressive anterior neck swelling developed, associated with intermittent positional dyspnea and orthopnea.
Preoperative assessment	CT of the neck and chest demonstrated a giant multinodular retrosternal goiter extending deeply into the superior mediastinum, below the aortic arch, with marked rightward tracheal deviation and severe extrinsic tracheal compression. The minimum tracheal luminal diameter was approximately 7 mm. Comprehensive preoperative laboratory, cardiovascular, airway, and thyroid assessments were performed.
Preoperative airway planning	Airway assessment identified relative macroglossia, a high-arched palate, short neck, neck circumference of 43 cm, sternomental distance < 12 cm, mouth opening of 4 cm, thyromental distance < 6 cm, Modified Mallampati class IV, reduced neck mobility, and a positive upper lip bite test. Cervical spine radiographs excluded atlantoaxial instability. Awake fiberoptic intubation, even under sedation, was considered unsuitable because of severe intellectual disability and anticipated inability to cooperate.
Day of surgery before induction	A multidisciplinary airway and surgical strategy was established involving anesthesiologists, endocrine surgeons, cardiothoracic surgeons, and perfusionists. Tolerance of the ramped position was assessed and was well tolerated without clinically significant respiratory deterioration or desaturation. On arrival in the operating room, SpO₂ was 92% on room air and increased to 94% after ramped positioning without supplemental oxygen. High-flow nasal cannula oxygen at FiO₂ 1.0 and 40 L/min was initiated 20 min before induction, achieving SpO₂ 100%.
Induction and intubation	Controlled intravenous induction was performed with propofol 150 mg, fentanyl 150 µg, and succinylcholine 100 mg. Video laryngoscopy using a STORZ C-MAC Macintosh #3 blade provided a Cormack–Lehane grade I view. A 6.0-mm internal-diameter endotracheal tube was passed successfully on the first attempt without hypoxemia or hemodynamic instability. Flexible bronchoscopy confirmed tube position and airway patency beyond the compressed segment. Vecuronium was administered only after definitive airway control.
Surgery	Total thyroidectomy was performed through a low transverse cervical incision with full median sternotomy and intraoperative nerve monitoring. Operative time was 185 min and estimated blood loss was 250 mL.
End of surgery/extubation	An adequate cuff leak was demonstrated. After full consciousness, adequate spontaneous ventilation, stable oxygenation and hemodynamics, and quantitative neuromuscular recovery with a train-of-four ratio of 0.9 after neostigmine, the patient was safely extubated in the operating room. No formal dynamic assessment for tracheomalacia was performed.
Postoperative days 0–1	The patient was monitored overnight in the intensive care unit and received BiPAP for 6 h with FiO₂ 50%, pressure support 16 cm H₂O, and PEEP 8 cm H₂O. Thoracic drains were removed on postoperative day 1. Respiratory exercises and chest physiotherapy were provided. No respiratory or other major postoperative complications occurred.
Postoperative day 5	The patient was discharged home in stable clinical condition. No clinically significant cervical hematoma, bleeding, renal dysfunction, hypocalcemia, voice change, or sternal complication was reported.
1-month follow-up	The patient remained clinically well without recurrent respiratory symptoms or other reported postoperative complications.

↓ Table 2. Timeline of the Patient’s Clinical Presentation, Diagnostic Assessment, Airway Management, Surgery, and Postoperative Course

Time

Clinical event

BiPAP: bilevel positive airway pressure; PEEP: positive end-expiratory pressure.

18 months before surgery

Progressive anterior neck swelling developed, associated with intermittent positional dyspnea and orthopnea.

Preoperative assessment

CT of the neck and chest demonstrated a giant multinodular retrosternal goiter extending deeply into the superior mediastinum, below the aortic arch, with marked rightward tracheal deviation and severe extrinsic tracheal compression. The minimum tracheal luminal diameter was approximately 7 mm. Comprehensive preoperative laboratory, cardiovascular, airway, and thyroid assessments were performed.

Preoperative airway planning

Airway assessment identified relative macroglossia, a high-arched palate, short neck, neck circumference of 43 cm, sternomental distance < 12 cm, mouth opening of 4 cm, thyromental distance < 6 cm, Modified Mallampati class IV, reduced neck mobility, and a positive upper lip bite test. Cervical spine radiographs excluded atlantoaxial instability. Awake fiberoptic intubation, even under sedation, was considered unsuitable because of severe intellectual disability and anticipated inability to cooperate.

Day of surgery before induction

A multidisciplinary airway and surgical strategy was established involving anesthesiologists, endocrine surgeons, cardiothoracic surgeons, and perfusionists. Tolerance of the ramped position was assessed and was well tolerated without clinically significant respiratory deterioration or desaturation. On arrival in the operating room, SpO₂ was 92% on room air and increased to 94% after ramped positioning without supplemental oxygen. High-flow nasal cannula oxygen at FiO₂ 1.0 and 40 L/min was initiated 20 min before induction, achieving SpO₂ 100%.

Induction and intubation

Controlled intravenous induction was performed with propofol 150 mg, fentanyl 150 µg, and succinylcholine 100 mg. Video laryngoscopy using a STORZ C-MAC Macintosh #3 blade provided a Cormack–Lehane grade I view. A 6.0-mm internal-diameter endotracheal tube was passed successfully on the first attempt without hypoxemia or hemodynamic instability. Flexible bronchoscopy confirmed tube position and airway patency beyond the compressed segment. Vecuronium was administered only after definitive airway control.

Surgery

Total thyroidectomy was performed through a low transverse cervical incision with full median sternotomy and intraoperative nerve monitoring. Operative time was 185 min and estimated blood loss was 250 mL.

End of surgery/extubation

An adequate cuff leak was demonstrated. After full consciousness, adequate spontaneous ventilation, stable oxygenation and hemodynamics, and quantitative neuromuscular recovery with a train-of-four ratio of 0.9 after neostigmine, the patient was safely extubated in the operating room. No formal dynamic assessment for tracheomalacia was performed.

Postoperative days 0–1

The patient was monitored overnight in the intensive care unit and received BiPAP for 6 h with FiO₂ 50%, pressure support 16 cm H₂O, and PEEP 8 cm H₂O. Thoracic drains were removed on postoperative day 1. Respiratory exercises and chest physiotherapy were provided. No respiratory or other major postoperative complications occurred.

Postoperative day 5

The patient was discharged home in stable clinical condition. No clinically significant cervical hematoma, bleeding, renal dysfunction, hypocalcemia, voice change, or sternal complication was reported.

1-month follow-up

The patient remained clinically well without recurrent respiratory symptoms or other reported postoperative complications.

↓ **Table 3.** Summary of Perioperative Management and Clinical Outcome in Our Patient With Down Syndrome and Giant Retrosternal Goiter
Phase	Challenge	Management in our case	Outcome
BiPAP: bilevel positive airway pressure; CPB: cardiopulmonary bypass; CT: computed tomography; ETT: endotracheal tube; ICU: intensive care unit; IV: intravenous; LMA: laryngeal mask airway; TIVA: total intravenous anesthesia; TOF: train-of-four; VA-ECMO: veno-arterial extracorporeal membrane oxygenation.
Preoperative assessment	Giant retrosternal goiter with severe tracheal compression (∼7 mm), rightward deviation, and extension below the aortic arch	Multidisciplinary airway and surgical assessment; CT-based airway and mediastinal evaluation	Critical airway narrowing identified; combined cervical–sternotomy approach planned
Airway assessment	Down syndrome, macroglossia, short neck, Mallampati IV, reduced neck mobility, obesity, and anticipated difficult mask ventilation/intubation	Comprehensive multifactorial airway assessment; cervical spine radiographs	High-risk airway recognized; atlantoaxial instability excluded
Airway strategy	Severe tracheal compression with potential airway compromise after induction; awake fiberoptic intubation considered unsuitable because of inability to cooperate	Video laryngoscopy selected as primary technique; flexible bronchoscopy and rescue strategies prepared	Individualized primary and rescue airway plan established before induction
Rescue preparedness	Potential inability to ventilate or intubate after induction	LMA and bronchoscopy immediately available; surgical airway and transfer to a facility equipped for femoro-femoral VA-ECMO/CPB planned if required	Advanced rescue options available throughout airway management
Induction and intubation	Critical tracheal narrowing and risk of respiratory/hemodynamic deterioration	IV induction with propofol, fentanyl, and succinylcholine; STORZ C-MAC video laryngoscopy; smaller ETT sizes prepared	First-attempt intubation with grade I view; 6.0-mm ETT passed beyond stenosis without hypoxemia or hemodynamic instability; position confirmed by bronchoscopy
Surgery and maintenance	Extensive cervical and mediastinal disease requiring major surgery	TIVA with propofol/remifentanil; invasive arterial monitoring; total thyroidectomy through cervical incision and median sternotomy	Operative time 185 min; blood loss 250 mL; no major intraoperative complications
Extubation	Risk of postoperative airway obstruction and possible tracheomalacia after long-standing compression	Cuff-leak test; full consciousness, adequate spontaneous ventilation, stable oxygenation/hemodynamics, and TOF ratio 0.9 confirmed before extubation	Successful operating-room extubation without immediate airway compromise; tracheomalacia not formally excluded
Postoperative care and outcome	Down syndrome, obesity, sternotomy, and risk of postoperative respiratory compromise	BiPAP for 6 h, overnight ICU monitoring, early respiratory exercises/chest physiotherapy, multimodal analgesia	Uneventful respiratory recovery; no significant postoperative respiratory complication; discharge on postoperative day 5

↓ Table 3. Summary of Perioperative Management and Clinical Outcome in Our Patient With Down Syndrome and Giant Retrosternal Goiter

Phase

Challenge

Management in our case

Outcome

BiPAP: bilevel positive airway pressure; CPB: cardiopulmonary bypass; CT: computed tomography; ETT: endotracheal tube; ICU: intensive care unit; IV: intravenous; LMA: laryngeal mask airway; TIVA: total intravenous anesthesia; TOF: train-of-four; VA-ECMO: veno-arterial extracorporeal membrane oxygenation.

Preoperative assessment

Giant retrosternal goiter with severe tracheal compression (∼7 mm), rightward deviation, and extension below the aortic arch

Multidisciplinary airway and surgical assessment; CT-based airway and mediastinal evaluation

Critical airway narrowing identified; combined cervical–sternotomy approach planned

Airway assessment

Down syndrome, macroglossia, short neck, Mallampati IV, reduced neck mobility, obesity, and anticipated difficult mask ventilation/intubation

Comprehensive multifactorial airway assessment; cervical spine radiographs

High-risk airway recognized; atlantoaxial instability excluded

Airway strategy

Severe tracheal compression with potential airway compromise after induction; awake fiberoptic intubation considered unsuitable because of inability to cooperate

Video laryngoscopy selected as primary technique; flexible bronchoscopy and rescue strategies prepared

Individualized primary and rescue airway plan established before induction

Rescue preparedness

Potential inability to ventilate or intubate after induction

LMA and bronchoscopy immediately available; surgical airway and transfer to a facility equipped for femoro-femoral VA-ECMO/CPB planned if required

Advanced rescue options available throughout airway management

Induction and intubation

Critical tracheal narrowing and risk of respiratory/hemodynamic deterioration

IV induction with propofol, fentanyl, and succinylcholine; STORZ C-MAC video laryngoscopy; smaller ETT sizes prepared

First-attempt intubation with grade I view; 6.0-mm ETT passed beyond stenosis without hypoxemia or hemodynamic instability; position confirmed by bronchoscopy

Surgery and maintenance

Extensive cervical and mediastinal disease requiring major surgery

TIVA with propofol/remifentanil; invasive arterial monitoring; total thyroidectomy through cervical incision and median sternotomy

Operative time 185 min; blood loss 250 mL; no major intraoperative complications

Extubation

Risk of postoperative airway obstruction and possible tracheomalacia after long-standing compression

Cuff-leak test; full consciousness, adequate spontaneous ventilation, stable oxygenation/hemodynamics, and TOF ratio 0.9 confirmed before extubation

Successful operating-room extubation without immediate airway compromise; tracheomalacia not formally excluded

Postoperative care and outcome

Down syndrome, obesity, sternotomy, and risk of postoperative respiratory compromise

BiPAP for 6 h, overnight ICU monitoring, early respiratory exercises/chest physiotherapy, multimodal analgesia

Uneventful respiratory recovery; no significant postoperative respiratory complication; discharge on postoperative day 5