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J Anesth. 2018 Feb;32(1):54-61. doi: 10.1007/s00540-017-2428-x. Epub 2017 Nov 17.

Population analysis of predictors of difficult intubation with direct laryngoscopy in pediatric patients with and without thyroid disease.

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Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.
Department of Anesthesiology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA, 90048, USA.
Department of Anesthesia and Perioperative Care, UCSF Medical Center, San Francisco, CA, USA.
Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.



There are no data on the prevalence and predictors of difficult intubation (DI) in pediatric patients with thyroid disease. This study (1) assesses the prevalence of DI in patients with thyroid disease undergoing elective operations, (2) identifies other predictors of DI in children, and (3) evaluates the effect of DI on postoperative care and length-of-stay.


A single-center retrospective cohort analysis of procedures in patients assigned with an ICD-9 code for thyroid disease between June 2012 and February 2016. A comparative group was created which comprised of patients without thyroid disease receiving orthopedic or urologic surgeries to determine differences in DI prevalence. Univariate analyses compared demographics and intubation details between groups, and logistic regression identified independent variables associated with DI. Patients with and without DI were compared based on procedure duration, PACU-LOS, and escalation-of-care.


DI prevalence was greater in the thyroid group (4.9%, 51/1046) compared to the non-thyroid group (2.6%, 33/1289) (OR 1.95, 95% CI 1.25-3.05; p = 0.003). DI was associated with younger age, higher American Society of Anesthesiologists (ASA) class, and smaller body habitus (p < 0.001 for all comparisons). Congenital hypothyroidism (OR 2.49, 95% CI 1.44-4.32; p = 0.002)) and acquired hypothyroidism (OR 2.20, 95% CI 1.42-3.41; p < 0.001) were seen in a greater proportion of DI patients. After adjustment for demographic confounders, age and ASA class were independently associated with DI (p < 0.05), while hypothyroidism did not reach statistical significance (p = 0.077). Direct laryngoscopy (DL) was most frequently used as the successful subsequent maneuver in securing the airway in DI patients. A longer PACU length-of-stay was seen after procedures with DI (p < 0.001).


Elective pediatric surgical patients with thyroid-related diagnoses at our institution had a higher prevalence of DI than those without thyroid disease, but this finding could not be isolated to thyroid pathology. Repeat DL achieves successful intubation in the majority of DI patients. DI patients often require longer recovery times due to prolonged cardiopulmonary monitoring.


Airway management; Cohort studies; Intubation; Laryngoscopy; Pediatrics; Thyroid diseases

[Indexed for MEDLINE]

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