The anesthetic management of a 63-year-old woman with a large bilateral thyroid goiter causing tracheal deviation and compression was described. Thyroidectomy was planned for severe airway compromise. Extracorporeal membrane oxygenation (ECMO) was established before anesthesia induction. The trachea was intubated, beginning with a small cuffed endotracheal tube that was inflated and sequentially replaced with larger tubes until a 7-mm tube was placed to dilate the trachea successfully. ECMO was discontinued after the airway was established. There was minimal bleeding during thyroidectomy.