Awake Fiberoptic Intubation for Severe Tracheal Compression Caused by a Multinodular Goiter: A Case Report

Massive multinodular goiters may cause critical tracheal compression and distortion of anterior neck anatomy, rendering both conventional airway management and front-of-neck access (FONA) unsafe. Awake fiberoptic intubation (AFOI) is often recommended, but failure may still occur, requiring reassessment and alternative rescue strategies. We report a 53-year-old male with a long-standing multinodular goiter causing severe tracheal narrowing (minimum diameter, 6.2 mm) and marked deviation. An initial AFOI attempt failed due to inadequate tolerance and airway collapse. Following multidisciplinary reassessment and optimization of topical anesthesia and airway strategy, a second AFOI was successfully performed. General anesthesia and thyroidectomy proceeded uneventfully. Extubation was deferred due to concern for postoperative secondary tracheomalacia. Following airway assessment and staged weaning, the patient was extubated over an airway exchange catheter and recovered without complications. This case highlights the importance of structured decision-making in anticipated difficult airway scenarios where FONA is not feasible. It emphasizes that failed AFOI should prompt reassessment rather than abandonment of the awake approach and that extubation represents a second high-risk airway intervention requiring planning. The role of extracorporeal membrane oxygenation (ECMO) as a rescue strategy in extreme cases is discussed. In patients with severe goiter-related tracheal compression, successful airway management relies on multidisciplinary planning, optimization of awake intubation technique, and a staged extubation strategy supported by airway exchange devices.