Correspondence

Use of the GlideScope for placement of a recurrent laryngeal nerve monitoring endotracheal tube

The close proximity of the recurrent laryngeal nerves (RLN) to the thyroid gland places the nerve at risk of injury during thyroid surgery. Furthermore, thyroid surgery can put both the right and the left RLNs at risk during a single surgical procedure. RLN injury or invasion by cancer can cause vocal cord paralysis (VCP) that leads to substantial morbidity arising from voice, swallowing and breathing issues. Unilateral VCP can lead to voice changes that may greatly impact professional voice users, as well as can cause potential dysphagia and aspiration, whereas bilateral VCP may require tracheostomy. Along with excellent anatomical understanding, intraoperative neural monitoring (IONM) can help in nerve mapping and identification. Additionally, IONM can help predict neural injury as well as play a role in management of invaded nerve and surgical decision-making. Several general surgical principles should be closely followed to protect RLNs during thyroid surgery. Based on the pathology and indication for surgery, different surgical approaches to the RLN: lateral, superior or inferior, can be used. Following standards of IONM and a good understanding of normative IONM characteristics for RLN are essential for accurate monitoring and proper interpretation of IONM data during a thyroid surgery. With the increasing use of IONM and given its value in intraoperative surgical management, it is important that the surgeon has a preoperative discussion with the patient regarding the use and implications of IONM on intraoperative surgical decision-making.

The use of videolaryngoscopy continues to play a larger role in the approach to patients with airway pathology. Looking specifically at patients with potential difficulty in ventilation and intubation due to thyroid goiter, video laryngoscopy may provide a faster and easier technique to secure the airway compared to direct laryngoscopy.

In the case we will present to you, a 60-year-old female with a large goiter presented to a community hospital emergency room where she was found to be in respiratory distress with increased work of breathing. Urgent subtotal thyroidectomy was planned. The patient was intubated using a Glidescope technique and the airway was secured in a safe and timely fashion.

A literature review of PubMed and Web of Science of the use of videolaryngoscopy in goiter, difficult airway, and airway obstruction yielded information supporting the use of the video laryngoscopy as a first choice for laryngoscopy with a proven benefit over direct laryngoscopy.