Gurgling Sound During Thyroid Surgery
A gurgling sound during thyroid surgery is a critical warning sign of potential airway compromise that demands immediate recognition and systematic intervention using the SCOOP protocol if airway obstruction develops.
Immediate Recognition and Assessment
A gurgling sound represents a potential sign of airway compromise that requires urgent evaluation. This auditory finding may indicate:
- Difficulty swallowing or discomfort - part of the DESATS assessment criteria for post-thyroidectomy complications 1
- Early warning of hematoma formation - which can cause rapid airway obstruction even with small volumes 2
- Potential laryngeal edema or secretions - complicating the already at-risk airway 2
The DESATS approach should be immediately applied to assess severity: Difficulty swallowing/discomfort; increase in Early warning score; Swelling; Anxiety; Tachypnea/difficulty breathing; and Stridor 1, 3.
Critical Initial Actions
Immediately administer high-flow supplemental oxygen and position the patient head-up to optimize airway patency and reduce airway edema 1, 3. This positioning is crucial as the anatomical structures in the neck place patients at risk of rapid clinical deterioration 2.
- Alert the senior anesthetist immediately if there are any signs of airway compromise 2, 1
- Contact the duty surgeon and assemble the crash team 2
- Ensure portable lighting is available for adequate visualization 3
- Prepare emergency front-of-neck airway equipment including scalpel (number 10 blade), bougie, and cuffed 6.0 mm tracheal tube 2
Algorithmic Management Based on Airway Status
If Signs of Airway Compromise Are Present:
Proceed immediately to bedside hematoma evacuation using the SCOOP approach 2, 1, 3, 4:
- Skin exposure - expose the surgical site
- Cut sutures - cut subcuticular sutures
- Open skin - open skin to expose strap muscles
- Open muscles - open both superficial and deep strap muscle layers to expose trachea
- Pack wound - cover wound with pack
Local anesthetic infiltration is not required when opening the wound in this emergency situation 2, 4.
If Evacuation Fails to Resolve Airway Compromise:
Emergency tracheal intubation must be considered immediately, regardless of patient location 2. The intubation should be attempted after opening the wound and evacuating the hematoma to optimize conditions and prevent worsening laryngeal edema 2.
- Use videolaryngoscopy at the first attempt 2, 3, 4
- Consider a smaller tracheal tube and/or bougie as adjuncts 2, 4
- Confirm success with capnography 2, 4
- Limit the number of intubation attempts as multiple attempts exacerbate laryngeal edema 2, 3
If Cannot Intubate, Cannot Oxygenate:
Proceed immediately to scalpel cricothyroidotomy or emergency tracheostomy - these are preferred over cannula cricothyroidotomy as they reduce gas trapping, maximize respiratory gas exchange, and are associated with fewer complications including hypercapnia, barotrauma, and subcutaneous emphysema 2, 3.
Critical Pitfalls to Avoid
- Stridor is a late sign of airway compromise - intervention should not be delayed until stridor develops 1, 3, 4
- Do not rely on drains for reassurance - drains do not prevent hematoma formation, and clot formation may prevent free drainage, providing false reassurance 1
- Multiple intubation attempts worsen outcomes - early progression to front-of-neck airway should be considered rather than repeated attempts 2, 3
- Ongoing bleeding is not a contraindication to performing emergency front-of-neck airway 2
Post-Intervention Management
Following any emergency intervention:
- Transfer to level 2 or 3 care (PACU or ICU) for close postoperative observation 3, 4
- Maintain head-up positioning and avoid unnecessary positive fluid balances to reduce airway edema 3
- Monitor for tracheomalacia - which was noted in four of five patients with life-threatening airway compromise in one series 5
- Observe for laryngeal edema requiring close monitoring 5