A 70-year-old woman was scheduled for elective total thyroidectomy due to plunging intrathoracic goiter. The patient had a history of Hashimoto’s thyroiditis. The growth of thyroid had caused over time dysphagia, mild-to-moderate dyspnea and right vocal cord paralysis with mild dysphonia. Other significant medical history included obesity (body mass index 43), arterial hypertension, chronic atrial fibrillation, fibrocystic mastopathy, carotid atheroma, hiatal hernia and pharyngo esophageal diverticulum. Preoperative indirect laryngoscopy, performed by an otolaryngologist, pointed out a massive bombè of the hypopharyngeal wall to the right and hypomobile right vocal cord. The epiglottis was edematous and the glottis could not be identified. On physical examination, the tongue was large and a Mallampati’s score of 3 was determined. Finally, computed tomography scan revealed: 1) an intrathoracic goiter externalization to the right with cranial expansion toward the larynx and pharynx, and an axial deviation of the trachea to the right 2) right vocal cord paralysis in paramedian position 3) thyroid volume estimation of about 110 ml. Therefore a difficult intubation was expected. Because of the presence of large tongue, right vocal cord paralisys and massive bombè of the hypopharyngeal wall, a nasal fiberoptic intubation was planned. However, since the nasal intubation can be associated with bleeding especially in patients with coagulative disorders, as it was in this case, a NIM EMG® ETT with a small inner diameter was used. Indeed the NIM EMG® ETT outer diameter is larger than the corresponding standard tube [10.2 mm for a 7.0 NIM EMG tube vs. 9.5 mm for a standard 7.0 polyvinyl chloride tube]. Awake fiberoptic intubation was considered to be an appropriate choice because of the patient’s ability to cooperate, according to the American Society of Anestesiologist’s difficult airway algorithm []. After topical application of 2% lidocaine to nasal mucosa, we performed fiberoptic bronchoscopy (PentaxR FB-15P, Pentax Corporation, Tokyo, Japan) pre-mounted with a 6.0 mm inner diameter NIM EMG® EET through the nasal cavity, while the patient was spontaneously breathing. Oxygenation was obtained by using a face mask with 100% oxygen. As a consequence, oxygenation was adequate during the procedure. Intubation was performed under light sedation. The patient was premedicated with midazolam (0.03 mg/kg), fentanyl (3 mcg/kg), and propofol (1.5 mg/kg) based on predicted body weight. Prior to insertion, the tube was lubrificated with lidocaine gel. When the fiberscope’s tip was at the carina, the next step was to pass the endotracheal tube and additional lidocaine has been administered through the working channel of the bronchoscope in the trachea. A Cormak grade 2 view of the vocal cords was obtained, the NIM EMG® EET was passed easily and the video component of the fiberoptic allowed tube placement with confirmation on the video screen. For optimal electromyographic recording, the electrodes should be placed exactly between and perpendicular to vocal cords. The use of fiberoptic bronchoscopy allowed a correct visualization of vocal cords and so the optimal placement of NIM EMG® EET. Intubation time was 20 minutes. Anaesthesia was maintained with sevoflurane and fentanyl and the patient was stable for the entire duration of the intervention (240 minutes). Major nasal bleeding was not encountered. The patient was ventilated with an external positive end-expiratory pressure (PEEPe) of 8 cmH2O, a tidal volume of 8 ml/kg of predicted body weight and a respiratory rate of 13 breaths/min. The latter has been chosen to maintain normocapnia. At the of end surgery, the patient was taken to the intensive care unit, because of the need of performing extubation in a secure environment. The patient was extubated on the first postoperative day and she had no complications.