Introduction: Goiter (derived from the Latin word gutter-throat)¹ is a noncancerous palpable enlargement of the thyroid gland. The enlargement, if it exceeds the upper limit of the normal defined volume, is pathological. Goiter is a manifestation of deficient thyroid hormone production due to iodine (I) deficiency. Here we report a case of a very large endemic multinodular goiter and its management in a secondary care hospital. Case description: A 52-year-old female reported to the outpatient department with swelling in her neck for the past 30 years. On examination, there was a huge swelling in the neck extending superiorly up to the floor of the mouth, inferiorly up to the sternum and pendulous over the sternum with no intrathoracic extension. Ultrasound revealed a heterogeneous echotexture of the gland with multiple nodules. Computed tomography revealed a heterogeneously enhancing enlarged thyroid with no calcification with mild tracheal compression. Fine needle aspiration cytology revealed adenomatous hyperplasia in nodular goiter. Blood triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) levels are within normal limits. Upper gastrointestinal (GI) endoscopy was done, which revealed a postcricoid web. It was managed with bougie dilators under endoscopic guidance. A decision to do a total thyroidectomy was made in view of dysphagia and the chance of containing hidden malignancy. The intubation was smooth. A Gluck Sorenson incision was made, and dissection proceeded like a total thyroidectomy. The strap muscles were retracted laterally and not divided. Left lobe dissection was started, the gland was brought out of the wound, and the carotid artery and internal jugular vein were delineated. A recurrent laryngeal nerve was identified between the carotid artery and trachea and was traced up to the cricothyroid muscle on both sides. Parathyroid was identified and preserved on both sides. The thyroid gland was separated from the trachea dividing Berry's ligament, and removed in toto. There was minimal tracheomalacia. The wound was closed in layers with surgical drains. The patient was extubated the next day. Her voice was normal, and serum calcium was within normal limits on the next postoperative day. On postoperative day 2, patient developed transient hypocalcemia. The same was managed with oral calcium supplements and intravenous (IV) calcium boluses. The patient was discharged home on the 7th postoperative day. Discussion: Adequate blood reservation should be made if transfusion is necessary during or after surgery. Availability of ventilator facilities should be ensured before taking these patients for surgery. During intubation, a difficult airway should be anticipated, and an awake fiberoptic intubation facility should be ready in the operating room. Controlled hypotension during anaesthesia may be necessary for the reduction of overall blood loss and improved surgical field conditions.⁴ It would be ideal to have a nerve monitor in managing these cases, but we could demonstrate recurrent laryngeal nerve without it.⁷ The excess skin need not always be removed as it is stretched skin due to the swelling and returns to its original size after thyroid gland removal. The patient was extubated the next day in view of tracheomalacia. The patient was supplemented with a replacement dose of T4 the next day. The histopathological report was a colloid goiter. Conclusion: This huge goiter is preventable and could have been managed early. The intraoperative challenges with these huge goiters are distorted anatomy, bleeding and injury to vital structures, namely the trachea, esophagus, and great vessels. For huge goiters, we advocate Gluck Sorenson incision, no division of strap muscles, and no excision of the excess neck skin. Tracheomalacia and occult malignancy were the main concerns with this long-standing large goiter.⁸