An elderly woman in her fifties reported having severe neck edema that extended down both sides of her neck. Six years ago, the patient appeared normal until a tumor was discovered in the middle of her neck. Painlessly, and slowly, it occurred. First, palpitations were the patient's complaint. The patient started having breathing difficulties when lying down as the edema got worse. It was necessary for her to sleep on her side or with two pillows. She began experiencing vocal hoarseness a year ago as well. A bronchopulmonary fistula has been treated in the past for the patient, and an ICD is in place. A thorough abdominal hysterectomy under spinal anesthesia had been performed on the patient six years ago.

The patient appeared to be of average build (166 cm in height and 65 kg in body weight). When the neck was examined, a bulge in the midline was seen, which moved when the patient deglutitioned. From superior to inferior retrosternal (fingers could not be placed behind the sternum), It stretched from the sternocleidomastoid's anterior to posterior. It is 10 x 5 x 3 cm in size. Numerous nodules were visible on the neck, with the right side having the most, and a consistency that ranged from soft to hard. Overlying the bulge were no engorged veins. None of the thyrotoxicosis-indicating eye symptoms were present. One could not feel the lymph nodes. There were no problems found during the upper airway examination, and Mallampati Grade 2. Even at normal extension, there was a significant restriction in neck flexion. An otolaryngologist demonstrated vocal movement with a video laryngoscopy. While the left voice cord was minimally limited, the right voice cord was very flexible.

The patient took 20 mg of carbimazole, and the results of the thyroid function tests were within normal ranges. The ECG displayed normal readings. Upon performing a neck ultrasonography, many nodules and measures of 6.8 cm for the right lobe, 5.5 cm for the left lobe, and 2.6 cm for the isthmus indicated a diffusely enlarged thyroid gland. Features of cystic degeneration and colloid goiter were found by fine-needle aspiration cytology of the enlargement. Before starting carbimazole tablets, thyroid scintigraphy was done, and the findings supported hyperthyroid status by showing a poisonous multinodular goiter featuring a high technetium absorption nodule. X-rays of the chest showed constriction of the trachea and retrosternal extension. On the CT chest, there was evidence of tracheal displacement to the right and oesophageal compression. Bilateral superficial cervical plexus block and epidural anesthesia were planned for the patient. The patient was informed about the surgery and provided with signed informed consent.

Thirty minutes before entering the operating room on the morning of surgery, the patient received an intramuscular shot of glycopyrrolate (0.2 mg). Multiparameter monitoring equipment, including an electrocardiogram (ECG), non-invasive arterial pressure cuff, and pulse oximeter, was applied after the patient was placed on the operating table. The baseline readings recorded, and they were within normal limits. The patient was made to sit in a chair. Parts are painted and draped. A cervical epidural puncture was performed at C7-T1, and a catheter was introduced and secured 9 cm from the skin. The patient was the    n positioned supine, and a bilateral cervical plexus block was administered under ultrasound guidance with 5ml of 0.25% bupivacaine on each side.

Figure 1: cervical epidural catheter insertion technique.

Figure 2: Patient positioned for surgery after the epidural technique.

Monitors were connected, and the patient was placed in a supine posture. The patient was sedated with 2 mg of midazolam and 200 mcg of fentanyl. Midazolam was injected at 1mg per hour. Fentanyl injections of 50 mcg were repeated every hour.

Table 1: Intraoperative maintenance of Epidural Anaesthesia.

Patient vitals were monitored, and baseline vitals were recorded intraoperatively. The intraoperative hemodynamics were steady. The thyroid gland was surgically removed. Post-procedure patient was awakened and responding to oral orders.

Massive thyroid swellings represent a significant difficulty for anaesthesiologists. WHO has classified goiters based on their size: Class I is a visible, palpable mass within the neck structure; Class II is a very big goiter involving retrosternal extension that causes tracheal deflection and pressing of the trachea and esophagus. Class 0 is a palpable mass within the neck structure. It is a Class II goiter in our patient. The substernal component is present in up to 45 percent of goiter patients. The three varieties of retrosternal goiters are Grade I, which is located above the aortic arch, Grade II, which is located intermediate between the aortic arch and the pericardium, and Grade III, which is located below the right atrium. Large, retrosternal goiters significantly impede airway function by compromising other airway structures and producing tracheal compression and deviation. Another problem with large goiters is that when the patient is sedated or given anesthesia, the soft palate and epiglottis fold back into the posterior pharyngeal wall, blocking the airway. As a result of the limited space for bronchoscope maneuvering, airway visibility would be compromised. As a result, we concluded that providing cervical epidural anesthesia with bilateral cervical plexus block would be useful for this patient, who also has a treated bronchopulmonary fistula.

Two issues complicate safe anesthesia for thyroid surgery: (1) the likelihood of tracheal deflection or compression due to an enlarged thyroid; and (2) the possibility of hemodynamic abnormalities, such as arrhythmias and hypotension, caused by thyroid function. In some cases, administering traditional general anesthesia with endotracheal intubation may be impractical or even harmful. The stressful process of endotracheal intubation can produce laryngeal edema. Muscle relaxants, anesthetic gases, and propofol can all cause arrhythmias when hidden hypothyroidism or hyperthyroidism is present. Regional anesthesia is regarded to be the safest alternative in situations similar to those in which general anesthesia becomes risky. The majority of hand, upper limb, shoulder, and upper thoracic wall procedures—including mastectomy—have been performed under cervical epidural anesthesia. It has also been utilized to treat complex regional pain syndromes including the upper limb, to treat head and neck tumors through neck dissection, and to treat carotid artery surgery. Every author has reported excellent surgical anesthesia and high patient acceptance. There have been no documented incidents of the anesthesia failing or the necessity to employ a different anesthetic technique.

According to our research, Cervical epidural Anaesthesia ( CEA ) had no impact on pulmonary function. Our patients showed no change in their peripheral arterial oxygen saturation or breathing patterns on pulse oximetry. As a coping mechanism, acute diaphragmatic paralysis should cause the abdominal muscles to contract forcefully. Our patient did not exhibit this. In addition, our patient never experienced post-operative pulmonary atelectasis. Another major worry has been how CEA affects hemodynamic stability and heart rate. The cardiac sympathectomy caused by CEA may result in a reduction in the rhythmic regulation of the cardiac cycle [1]. This could lead to a drop in the mean blood pressure and a non-increasing heart rate.  In our case, hemodynamic imbalance did not happen [3,4].

When undergoing CEA, our patients were sedated but not unconscious. In the event of recurrent laryngeal nerve injury—which might happen following thyroid surgery—this permits continued vocal communication with the patient and prompt diagnosis [5,6].

We have demonstrated, in conclusion, that CEA is an alternative to general anaesthesia and that, in the event that Fiber-optic bronchoscopy is not an option for managing a patient’s airway, it should be taken into consideration.

Take Home Points: Cervical Epidural anesthesia is better for complicated airway involvement for neck surgeries, upper limb surgeries.

Regional Advantages: No airway involvement, there will be no post-operative general anesthesia complications. There is no poly pharmacy involved and easy ambulation after surgery.

1. Khanna R, Singh D. Cervical epidural anesthesia for thyroid surgery. Kathmandu Univ Med J. 2024; 7: 242-245.
2. Kaur H, Kataria AP, Muthuramalingapandian M, Kaur H. Airway considerations in case of a large Multinodular Goiter. Anesth Essays Res. 2017; 11: 1097-1100.
3. Bajwa SJ, Sehgal V. Anesthesia and thyroid surgery: The never-ending challenges. Indian J Endocrinol Metab. 2013; 17: 228-234.
4. Kamat S, Subramanian P, Eswaran K. Thyroid Surgeries under bilateral superficial cervical plexus block – A Case Series. J Anaes Crit Car Repor. 2021.
5. Jain G, Bansal P, Garg GL, Singh DK, Yadav G. Comparison of three different formulations of local anesthetics for cervical epidural anesthesia during thyroid surgery. Indian J Anaesth. 2012; 56: 129-134.
6. Stevens RA, Frey K, Sheikh T, Kao TC, Mikat-Stevens M. Morales M. Time course of the effects of cervical epidural anesthesia on pulmonary function. Reg Anesth Pain Med. 1998; 23: 20-24.