ULTRASOUND GUIDED BILATERAL INTERMEDIATE CERVICAL PLEXUS BLOCK AS AN ALTERNATIVE TO GENERAL ANAESTHESIA IN PATIENT FOR TOTAL THYROIDECTOMY WITH DIFFICULT AIRWAY: CASE SERIES.

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O.K. Adebayo¹, A.O. Ojedoyin¹, D.G. Efe¹, J.O. Morhason-Bello²

1. Department of Anesthesia, University College Hospital, Ibadan.
2. Department of Orthopedics and Trauma, University College Hospital, Ibadan.

Abstract

Background: Total thyroidectomy is traditionally performed under general anaesthesia, which can be challenging in patients with difficult airways. This case series explores the use of ultrasound-guided bilateral intermediate cervical plexus block (US-BICPB) as an alternative anaesthetic technique for patients undergoing total thyroidectomy with potential or actual difficult intubation.

Methods: Four patients scheduled for total thyroidectomy with identified difficult airway management were included. US-BICPB was performed using a mixture of 0.5% bupivacaine and 1% lidocaine with adrenaline. Sensory block was assessed, and patients were monitored for hemodynamic stability, pain scores, and adverse events.

Results: All four patients successfully underwent total thyroidectomy under US-BICPB without conversion to general anaesthesia. Patients remained hemodynamically stable throughout the procedures, with pain scores remaining at 2 or below on the Numerical Rating Scale (NRS) for several hours postoperatively. No major complications were reported. Patients expressed satisfaction with the technique and were discharged within 2-3 days post-surgery.

Conclusion: US-BICPB appears to be an effective and safe alternative anaesthetic technique for total thyroidectomy in patients with difficult airways. This approach may offer advantages in terms of airway management, post-operative pain control and patient satisfaction. Further studies with larger sample sizes are needed to confirm these findings and establish optimal protocols for patient selection and block administration.

Keywords: Dementia, Older adults, Clinical profile, Clinical pattern, Comorbidity, Behavioural symptoms

Introduction

Thyroid disease is the second most common endocrine disease in Africa and Nigeria.^1,2 One of the modalities for treatment of goiter is thyroidectomy, a surgery commonly done for the removal of an enlarged thyroid glands, the commonest cause of thyroid gland enlargement in our environment is simple multinodular goiter ^2,3 Thyroidectomy is usually done under general anaesthesia for adequate relaxation and largely because of airway concerns.⁴ However, cases done under local anaesthesia and bilateral subcutaneous cervical plexus blocks have been reported. It is said to offer better post operative analgesia while also eliminating the need for endotracheal intubation which might be difficult considering the relation of the mass to the larynx and trachea and in situations of huge thyroid mass. ^4,5

Thyroidectomy produces mild to severe pain, particularly within 24 hours of operation. Surgical operations or general anaesthesia can induce discomfort in swallowing, a burning sensation in the throat, nausea, and vomiting. Several attempts have been undertaken to prevent and treat these complications, including the use of opioids and nonsteroidal anti-inflammatory medications under local or regional anaesthesia ^5,6. There are different adjuncts that have been explored in management of intraoperative and post operative pain in thyroid surgery which include local wound infiltration and bilateral cervical plexus block whether deep or subcutaneous (intermediate or superficial). Bilateral cervical plexus block for thyroidectomy is alternative form of anaesthesia for thyroid operations. This could be combination of deep and subcutaneous block or only subcutaneous with the same efficacy.⁵

Different methods like landmark method and ultrasound guided method have been employed in cervical plexus block successfully. ^4,5 Ultrasound guidance was, however, found to be more effective in pain reduction and safer as it reduced need for high dose local anaesthetic agent and risk of intravascular drug. ⁵ When faced with a patient for total thyroidectomy with a difficult airway, ultrasound-guided bilateral subcutaneous cervical plexus block can be considered as a valuable alternative. This technique offers a safe and effective method for providing intraoperative and postoperative analgesia, while reducing the need for general anaesthesia. In addition, it can help minimize the risks associated with airway management in patients with challenging airways. By targeting the cervical plexus under ultrasound guidance, precise and localized anaesthesia can be achieved, leading to improved patient outcomes and satisfaction. In this article, we explored the benefits and techniques of ultrasound-guided bilateral intermediate cervical plexus block (US- BICPB) in the context of total thyroidectomy with difficult airway.

We report four cases of total thyroidectomy done under ultrasound guided cervical plexus block in patients with potential and actual difficult intubation at University College Hospital, Ibadan.