Long standing goitre with altered airway anatomy includes a high risk for airway management. In this case we discuss about a patient who had a long standing goitre and also presented with atrial fibrillation which was even more challenging for the anaesthetic management. Preoperative investigation showed 14 x 5.8 x 8.9cms in right lobe and 13.3 x 5.9 x 7cms in the left lobe with moderate tracheal compression. Anaesthesia was induced with sedation and supplemental oxygenation and intubation was performed using flexible fibre optic laryngoscope with flexometallic endotracheal tube. It was a challenge to avoid any pressor response during flexible laryngoscopy. And identifying that hyperthyroidism is a causative factor of atrial fibrillation plays a crucial role in management.