Successful awake fibreoptic nasotracheal intubation in a patient with a large thyroid mass undergoing total thyroidectomy

Long-standing large thyroid masses can distort airway anatomy through tracheal deviation and compression and restrict neck mobility. These changes may make conventional tracheal intubation difficult. Awake fibreoptic intubation offers an alternative by maintaining spontaneous ventilation and airway tone during airway instrumentation. We describe the perioperative airway management of a 50-year-old woman with a large papillary thyroid carcinoma scheduled for total thyroidectomy. Airway assessment revealed restricted neck movements, while imaging demonstrated tracheal deviation and narrowing. Awake fibreoptic nasotracheal intubation was planned, with preparation of a difficult airway cart and backup strategies. Following topical airway anaesthesia, the bronchoscope was advanced through the right nostril, and a cuffed endotracheal tube was positioned under direct fibreoptic guidance. General anaesthesia was induced after confirmation of tube placement. Surgery lasted eight hours. Elective postoperative ventilation was continued because of prolonged surgery, laryngeal oedema and anticipated tracheomalacia. The patient underwent ventilator weaning and extubation the following morning. This case illustrates the importance of individualized airway assessment, adequate topical anaesthesia, maintenance of spontaneous ventilation during intubation, and a planned postoperative airway strategy. Clear communication and readiness for alternative techniques remain essential.