Anesthetic management of a patient with a giant goiter undergoing hip arthroplasty: A case report

Abstract

Introduction: This case report outlines the anesthetic management of a 73-year-old male with a giant multinodular goiter and uncontrolled hyperthyroidism undergoing hip arthroplasty. It highlights the challenges of balancing airway safety, endocrine stability, and surgical urgency in patients with anatomically complex goiters, emphasizing the role of multidisciplinary collaboration and spinal anesthesia as an alternative to high-risk general anesthesia.

Case presentation: The patient, refusing thyroidectomy and tracheostomy, presented with a displaced femoral neck fracture and severe tracheal narrowing. Preoperative optimization included methimazole and potassium iodide to stabilize thyroid function. Spinal anesthesia using hyperbaric bupivacaine, dexmedetomidine, and fentanyl achieved a T8 sensory block, enabling uneventful cemented bipolar hemiarthroplasty. Intraoperative hemodynamics remained stable, with no sedation or airway intervention required.

Discussion: Spinal anesthesia circumvented airway manipulation risks, while adjuncts prolonged analgesia without respiratory compromise. The multidisciplinary approach addressed conflicting priorities: endocrine stabilization, surgical urgency, and airway safety. Postoperative care adhered to Enhanced Recovery After Surgery (ERAS) principles, with early mobilization and non-opioid analgesia. The absence of thyroid storm or complications validated the protocol.

Conclusion: This case demonstrates spinal anesthesia's efficacy in patients with giant goiters undergoing non-thyroid surgery, particularly when airway risks preclude general anesthesia. Success relied on interdisciplinary collaboration, preoperative optimization, and tailored pharmacology. Future research should explore standardized protocols for non-compliant patients and optimal adjunctive drug regimens in spinal anesthesia for high-risk populations.

Keywords: Airway obstruction; Anesthesia, spinal; Goiter; Hip arthroplasty; Thyroid storm.

Fig. 1

Clinical image of the patient demonstrating. A. Anterior view shows asymmetrical mass, extending below the chin and into the lower cervical area suggesting a retrosternal lesion, B right lateral view, C. left lateral view of the neck.

Fig. 2

An axial cut of the CT image of the patient's neck showed the presence of a large thyroid mass lesion with heterogeneous density, causing significant asymmetry that displaced adjacent anatomical structures, including vascular and airway components (tracheal internal diameter of 4.67 mm).

Fig. 3

Multidisciplinary algorithm for airway management, anesthetic technique selection, and contingency planning in patients with giant goiters.