Usefulness of ultrasound-guided placement of a needle to the trachea in a patient with anaplastic carcinoma thyroid for aiding tracheostomy - A case study

Dear Editor,

Anaplastic thyroid carcinoma (ATC) is an uncommon malignancy and has a poor prognosis. Its usual presentation is a rapidly growing neck mass with severe life-threatening stridor.[1,2] We report a case of a 52-year-old female patient with ATC who presented with stridor and was scheduled for an emergency tracheostomy. On examining the patient, a large mass (15 × 10 cm) in front of the neck extending to both sides was present. She could not lie down due to breathlessness. Her trachea was not palpable, and X-ray neck was not available. After topicalising the airway with lignocaine jelly and spray, we attempted awake fibreoptic bronchoscope guided tracheal intubation nasally, with the patient sitting while facing the anaesthesiologist. As the epiglottis became visible, 4 ml of 4% lignocaine was injected through the working port of the bronchoscope, and the airway was secured with a 6.5-mm cuffed endotracheal tube. During bronchoscopy, we observed that the larynx and trachea were grossly displaced to the left side. After confirming the correct tracheal placement of the endotracheal tube (with regular end-tidal carbon dioxide waveforms), the patient received intravenous fentanyl 2 µg/kg, midazolam 1 mg, propofol 2 mg/kg, and atracurium 0.5 mg/kg. The patient was then positioned supine for tracheostomy, with the neck being extended by using a small roll under the shoulders. However, due to swelling of the thyroid, the surgeons found it challenging to locate the trachea. Under ultrasonographic guidance (FUJIFILM SonoSite, Inc. Bothell WA 98021 USA, linear probe13–6MHz) the trachea was identified to be approximately 5 cm lateral to the midline on the left side, at 4 cm depth from the skin embedded in the thyroid swelling. The 16G intravenous cannula needle was passed from the nearest skin point to the trachea through the thyroid mass using the out-of-plane approach [Figure 1a]. Dissection was carried out along the needle, the trachea was exposed [Figure 1b], and the tracheostomy tube was passed into the trachea successfully.

Figure 1.

(a) Ultrasound image showing needle tip entering the trachea (b) Needle as a guide during the tracheostomy procedure

Tracheotomy is usually difficult in patients with ATC because of extensive tumours in front of the trachea, which makes it challenging to identify the trachea. This sometimes necessitates performing an isthmectomy to obtain adequate access.[3] Due to difficulty identifying the trachea, awake fibreoptic intubation may be the initial airway-management strategy over awake tracheostomy when such patients present using stridor.[4] For localising the trachea with the needle using ultrasonography, we used the out-of-plane approach to minimise the distance from the skin to the trachea and also to reduce trauma.

Locating the trachea using ultrasound is an established technique used during percutaneous tracheostomy which could also be helpful in patients with large thyroid tumours.[5] The advantage of placing a needle in the trachea through the most superficial area is that dissection towards the trachea becomes easier for surgeons, and since the needle of a 16G intravenous cannula is thick and long, displacement during manipulation is less likely. Though real-time ultrasonography is an option, an ultrasound probe in the surgical field could hinder emergency tracheostomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the record, the patient consented to her images and other clinical information being reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.