**Large goiters**

Thyroid cancers or large goiters can be threatening to the upper airway by external airway compression, deviation, distortion, or even local invasion of the trachea. Long term compression may lead to softening of the trachea (tracheomalacia).

Involvement of the recurrent laryngeal nerve may jeopardize an already compromised airway by causing additional narrowing of the glottis. The status of the recurrent laryngeal nerve and glottis opening can be assessed by a routine preoperative flexible laryngoscopy.

**Figure 9.** *Obstructive cancer of the hypopharynx.*

**Airway Management:** Large extra-tracheal lesions should engender caution concerning airway management. In these cases, with a suspected difficult airway, a wake intubation is the most appropriate. The possible options: blind nasal, awake oral laryngoscopy, fiberoptic intubation or a wake tracheotomy.

