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Go Back       IAR Journal of Anaesthesiology and Critical Care | IAR J Anaes Crtic Cre. 2(3) | Volume:2 Issue:3 ( June 30, 2021 ) : 28-32
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DOI : 10.47310/iarjacc.2021.v02i03.006       Download PDF       HTML       XML

Anaesthetic Management of Retrosternal Goitre for Left Hemi Thyroidectomy – A Case Report


Article History

Received: 30.05.2021 Revision: 07.06.2021 Accepted: 19.06.2021 Published: 30.06.2021


Author Details

Dr. Deepak C. Koli1, Dr. Roly R. Mishra2, Dr. Vidhya N. Deshmukh3 and Dr. Hemant H. Mehta4


Authors Affiliations

1Consultant Anaesthesiologist, Department of Anaesthesia and Pain Management, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

2DNB student, Department of Anaesthesia and Pain Management, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

3Senior Consultant Anaesthesiologist, Department of Anaesthesia and Pain Management, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India

4Director and Head of the department, Department of Anaesthesia and Pain Management, Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, Maharashtra, India


Abstract: Large retrosternal goitre (RSG) usually poses a challenge to both anaesthesiologist as well as surgeon, as airway management in such case requires multidisciplinary discussion so as to formulate safe plan to secure the airway. Induction of anaesthesia and positioning may cause cardiorespiratory collapse and in severe cases cardiopulmonary bypass or veno-venous extracorporeal membrane oxygenation may be needed. Post-surgery extubating these patient constitutes another challenge due to risk of underlying tracheomalacia and may require prolonged ventilatory support or tracheal stenting. Authors describe successful management of a patient with long standing goitre for more than 20 years having retrosternal extension with tracheal narrowing and severe compression posted for left hemi thyroidectomy SOS total thyroidectomy. We secured the airway with intravenous induction by video laryngoscopy, after failed awake fiberoptic intubation.


Keywords: Retrosternal goitre, fiberoptic bronchoscopy, videolaryngoscope, intravenous induction, cuff leak test, thyroidectomy.


INTRODUCTION:

An enlarged thyroid gland once extends beyond the clavicle and enters into the thorax is termed as retrosternal goitre (RSG). It is more prevalent in females with 3:1 ratio compare to males, with high incidence in elderly females in their 5th and 6th decade (Larry Jameson, J., & De Groot, L. 2016).


A large goitre can bring about compression and deviation of trachea with resultant difficulty in breathing and swallowing, it can also cause vascular compression leading to superior vena cava syndrome resulting in to edema of face and upper body and ultimately postural collapse. Conservative treatment of symptomatic obstructive goitre can be done with radioiodine but it carries risk of transient thyroid enlargement with resultant airway obstruction hence it is relatively contraindicated hence surgery remains main option of treatment in which around 2% of retrosternal goitres are removed surgically by extra cervical approach (White, M.L. et al., 2008). In the case of RSG extending beyond aortic arch, aberrant thyroid tissue or conic shape sternotomy is required (Huins, C.T. et al., 2008; & Simó, R. et al., 2019).


In this case report we will talk through various approaches for securing airway along with the perioperative considerations in our patient with retrosternal goitre having severe tracheal compression.This case talks about in detail about the prerequisites of multidisciplinary team work for successful management of such high risk patients and thus improving safety standards of patient healthcare.


CASE REPORT:

A 60 years old female, weight 83.8kgs, height 158cms and BMI of 33.60kg/m2 admitted with the chief complaints of swelling over anterior part of neck since 20years with midnight interruption of sleep due to feeling of pressure on neck followed by coughing, there was no history of dysphagia , change in voice or difficulty in breathing. Patient was a known diabetic on oral hypoglycaemic agents Tab. Gliclazide 60mg twice a day & Tab. Metformin and Tab. Vidagliptin 500/50 mg twice a day, patient is euthyroid and not on any other medications.

On local examination, there was huge swelling on the anterior aspect of left side of neck approximately 10cms x 8cms, extending superiorly above the thyroid cartilage and inferiorly behind the suprasternal notch. On palpation the swelling had firm consistency and it moved with deglutition but at the same time it was impossible to get under the swelling, which indicated retrosternal extension. There was no evident resting tremor, lid lag, exophthalmos or palpable lymph nodes. On airway examination, patient had adequate mouth opening, Mallampatti class 2, multiple missing teeth with gap between upper central incisors, short neck, and slight restriction of neck movements both in flexion and extension with normal side to side movements, preoperatively indirect laryngoscopy was done to assess vocal cord movement which showed bilateral mobile vocal cords during speech and respiration.


On physical examination, pulse rate was 87/min, blood pressure in supine position was 150/90 mmhg, Spo2 98% on room air, routine blood investigation were within normal limit except Haemoglobin (Hb) 10.7gm, serum calcium was 9.2mg/dl and thyroid function test TSH, T3, T4 were within normal limits, CXR showed mild mediastinal widening with deviation of trachea to right side with severe compression due to overlying thyroid mass (Table/Figure-1), Computed Tomography (CT) chest with neck showed normal lung parenchyma and asymmetric thyromegaly, secondary to a large hypo-attenuating lesion with scattered foci of calcification in the left lobe measuring approximately 7.3 x 7.5cms in maximum transverse dimensions and 9.9cms in length, causing rightward tracheal and deviation and severe compression with luminal compromise, retrosternal extension along with oesophageal compression (Table/Figure 2). ECG and 2D ECHO were within normal limit. Fine Needle Aspiration Cytology (FNAC) done, it was suggestive of follicular neoplasm hence patient was posted for left hemi thyroidectomy SOS total thyroidectomy.


Considering difficult airway a multidisciplinary team discussion was done preoperatively to form strategy to secure airway safely.The prime concern in this patient was distal airway obstruction which may cause difficulty in successful endotracheal intubation with resultant cannot intubate and cannot ventilate (CICV) situation if airway not was not secured safely, hence cardiovascular surgeon and a perfusionist were kept stand by for emergency venovenous extracorporeal membrane oxygenation (VV-ECMO).


The primary plan of action was to secure the airway under ideal circumstances by using awake fiberoptic bronchoscopy, to pass the bronchoscope till carina and then slide over flexometalic tube over it, in case of failure of this plan, subsequent plan of action was to do intravenous induction and administering short acting muscle relaxant followed by video laryngoscope guided intubation. In case of difficulty in passing the tube beyond vocal cords, we decided to use micro laryngeal tube with smaller diameter. In the event of unsuccessful laryngoscopy with cannot intubate and cannot ventilate (CICV) scenario backup plan was to use venovenous extracorporeal membrane oxygenation (VV-ECMO) to deliver complete respiratory support as front of neck access (FONA) was impossible to perform with huge goitre.


Considering difficult airway patient was explained and counselled in detail about awake fiberoptic intubation during preoperative assessment and written informed consent was taken for same along with postoperative ICU and SOS ventilator support. On the day of surgery patient was kept fasting since midnight , nebulised with 4% lignocaine in the morning in ward before shifting to OT, in the preoperative room a wide bore cannula was taken and Inj. Glycopyrrolate 0.2mg given IV, nasal patties soaked with 2% lignocaine with adrenaline and oxymetazoline nasal drops inserted in both nostrils.


Patient was counselled again in preoperative room about awake fiberoptic (FOB) intubation and then was shifted to operation theatre (OT), the difficult airway cart was kept ready in OT. Once inside OT all standard ASA monitors were applied, pulse rate was 110/min, blood pressure 160/90 mmhg ,spo2 was 98% on room air, O2 by nasal prongs was started at 4l/min, airway preparation was done with oxymetazoline nasal drops, 2% lignocaine jelly applied nasally , patient was given Inj. Midazolam 0.5mg and Inj. Fentanyl 25mcg , Inj. Dexmedetomidine (Dexem) 2mcg/ml started at 0.5mcg/kg/hr infusion and then awake FOB tried but patient was highly uncooperative, despite all the measures awake FOB guided endotracheal tube placement was not successful, hence it was decided to go ahead with intravenous induction , patient was given Inj. Propofol 50mg and Inj. Ketamine 50mg after confirming bag and mask ventilation Inj. Succinylcholine 75mg was given and ( rigid bronchoscope and ventilating bougie and jet ventilation kept as standby) video laryngoscope guided laryngoscopy done, it showed Cormac Lehane grade 3 so over ventilating bougie, no 6.5 flexometalic tube railroaded in to trachea. Position of ET-tube confirmed by ETCO2 tracing and equal air entry on both sides of chest on auscultation. Patient was then given Inj. Atracurium 50mg and Inj. Fentanyl 50mcg and intraoperatively maintained with O2/ Air 50/50 and desflurane with MAC of 1.0 along with,Inj. Atracurium 0.5mg/kg/hr and Inj. Dexem 0.5mcg/kg/hr continuous infusions. Patient was hemodynamically stable throughout the surgery, left hemi thyroidectomy was done with cervical incision without sternotomy, left recurrent laryngeal nerve and both left parathyroids were preserved and thyroid mass specimen ( multinodular goitre) (Table/Figure 3) sent for histopathology.


Before extubation the surgeon examined the trachea and on palpation concluded that the rings were patent and didn’t showed any sign of weakness, also under deep anaesthesia the endoluminal side of trachea was inspected using the flexible bronchoscope, no airway collapse was seen. Direct laryngoscopy with video laryngoscopy done which showed symmetric vocal cords and there wasn’t any visible laryngeal oedema, with these findings we concluded that the patient could be safely extubated over ventilating bougie, as there were no signs of tracheomalacia, vocal cord paralysis or laryngeal oedema under anaesthesia. If post extubation patient showed desaturation or any sign of respiratory distress, stridor then our plan was to anaesthetize the patient with intravenous induction and reintubate, if failed then backup plan was VV-ECMO.


Hence, post-surgical closure once patient was conscious and had good spontaneous breathing efforts leak test was performed to exclude tracheomalacia which showed significant leak excluding tracheal collapse ,so patient was reversed with Inj. Glycopyrrolate 0.5mg and Inj. Neostigmine 2.5mg, after thorough oropharyngeal suction extubated over ventilating bougie and observed in OT for 30mins, patient was breathing normally and was maintaining saturation 100% with Hudson’s mask O2 @ 6lit/min.Patient shifted to ICU for overnight observation, rest of the postoperative course was uneventful and patient discharged on postoperative day 5.

Figure Image is available at PDF file

Figure 1: Cxr


Figure Image is available at PDF file

Figure 2. Hrct Chest


Figure Image is available at PDF file

Figure 3. Mng Surgical Specimen


DISCUSSION:

In case of patients with obstructive retrosternal mass entire perioperative period is challenging as there is a potential risk for total obstruction of the distal trachea after induction and due to tracheomalacia post extubation. The strategies for securing airway in case of severe trachea compression secondary to a retrosternal thyroid mass differed markedly ranging from performing the awake fiberoptic intubation, conventional intubation either after intravenous induction along with short acting muscle relaxant or inhalation induction or sedation along with jet ventilation over an airway exchange catheter. Backup plans were more uniform and differing between rigid bronchoscopy, extracorporeal membrane oxygenation and cardiopulmonary bypass


In our case we first had multidisciplinary team discussion which culminated into that if airway problem occurs most likely it will occur in subglottic area that’s distal obstruction.


Considering severe tracheal compression by thyroid mass we tried awake fiberoptic intubation first but patient was uncooperative despite all the measures, awake FOB guided endotracheal tube placement was not successful hence decision was taken to do go ahead with intravenous induction with adequate muscle relaxation because it would have provided better intubation conditions.


Theoretically, muscle relaxation and positive pressure ventilation can lead to gradual respiratory collapse due to reduction in functional residual capacity and decreased trans pleural pressure (Blank, R. S., & de Souza, D. G. 2011). Various airway algorithms affirm that ideal situation for securing airway is one in which patient is awake and breathing spontaneously with intact airway reflexes, however awake fiberoptic intubation also remains debatable as it carries risk of airway obstruction or laryngospasm after insertion of fiberoptic scope with resultant acute respiratory failure. Further other causes for failure of this method includes altered anatomy, concurrent sedation causing apnoea, poor skills, aspiration and contamination and problem during railroading the endotracheal tube over the scope (Popat. 2011). Spontaneous breathing can be preserved with inhalation induction but it can lead to obstructive breathing pattern and requires longer induction time for adequate depth anaesthesia with resultant increased risk of laryngospasm and bronchospasm (Dempsey, G. A. et al., 2013). In addition to this inhalation agents also causes muscle relaxation similar to intravenous drugs and muscle relaxants. Considering all these factors we agreed that we will try first awake fiberoptic intubation as we do it routinely in most of the head neck cancer cases considering its safety and keeping intravenous induction as our alternative plan for securing airway.


Most of the available literature with respect to airway management in the patients with obstructive retrosternal goitres is restricted mainly to case reports, case series and retrospective studies. Malpas et al.,. on systemic review concluded that, the extracorporeal membrane oxygenation ECMO can be used in patients with severe airway obstruction due to front of neck or tracheal disease in order to supply essential tissue oxygenation while efforts are taken to secure the definitive airway in controlled surroundings (Malpas, G. et al., 2018).


A retrospective review of the anaesthetic management in patients with retrosternal goitre extending up to aortic arch posted for thyroidectomy was performed in tertiary care centre with dedicated head neck surgery team, which concluded that in patients with benign retrosternal goitre induction with intravenous drugs followed by direct laryngoscopy by experienced person is a safe technique in a specialized tertiary centre (Dempsey, G. A. et al., 2013). Hence,we kept intravenous induction as our alternate plan in case awake |FOB intubation fails.


Thyroidectomy in postoperative period carries risk of airway compromise due to complications like bleeding, laryngeal oedema, tracheomalacia and damage to recurrent laryngeal nerve therefore it is necessary to have prior detailed team discussion to formulate extubation plan in these patients keeping in mind ‘At risk’ extubation algorithm (Findlay, J. M. et al., 2011).Our main concern post extubation was tracheomalacia and expiratory secondary dynamic airway collapse, various studies done in western population are not congruous about the prevalence of tracheomalacia due to different intrinsic pathology, contrasting definitions and publication bias (Malpas, G. et al., 2018; Simó, R. et al., 2019; & Cook, T. M. et al., 2011). In case of tracheomalacia, less invasive methods like extended positive airway pressure or temporary tracheostomy can be done. An airway stent or tracheal surgery may be required depending upon the disease severity.


In our case we extubated our patient over ventilating bougie so that in case of a postoperative airway emergency, it can be used as an access to railroad the endotracheal tube during laryngoscopy.


CONCLUSION:

In conclusion in patients with retrosternal goitre with tracheal compression it is necessary to have multidisciplinary team involvement to formulate the plan of successful perioperative management of these patients and also extracorporeal membrane oxygenation can be a safe option when contemplated in advance.


REFERENCES:

  1. Blank, R. S., & de Souza, D. G. (2011). Anesthetic management of patients with an anterior mediastinal mass: continuing professional development. Canadian Journal of Anesthesia/Journal canadien d'anesthésie58(9), 853.

  2. Cook, T. M., Morgan, P. J., & Hersch, P. E. (2011). Equal and opposite expert opinion. Airway obstruction caused by a retrosternal thyroid mass: management and prospective international expert opinion. Anaesthesia66(9), 828-836.

  3. Dempsey, G. A., Snell, J. A., Coathup, R., & Jones, T. M. (2013). Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. British journal of anaesthesia111(4), 594-599.

  4. Findlay, J. M., Sadler, G. P., Bridge, H., & Mihai, R. (2011). Post-thyroidectomy tracheomalacia: minimal risk despite significant tracheal compression. British journal of anaesthesia106(6), 903-906.

  5. Huins, C.T., Georgalas, C., Mehrzad, H., & Tolley, N.S. (2008). a new classification system for retrosternal goiter based on a systematic review of its complications and management. Int J Surg 6, 71-76.

  6. Larry Jameson, J., & De Groot, L. (2016). Endocrinology: Adult and Paediatric. 7thed... Philadelphia: Elsevier, Saunders; 2016. p. 1399416.

  7. Malpas, G., Hung, O., Gilchrist, A., Wong, C., Kent, B., Hirsch, G. M., & Hart, R. D. (2018). The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review. Canadian Journal of Anesthesia/Journal canadien d'anesthésie65(6), 685-697.

  8. Popat. (2011). NAP4. Chapter 14: fiberoptic intubation: uses and omissions pp. 114-120.

  9. Simó, R., Nixon, I. J., Vander Poorten, V., Quer, M., Shaha, A. R., Sanabria, A., ... & Ferlito, A. (2019). Surgical management of intrathoracic goitres. European Archives of Oto-Rhino-Laryngology276(2), 305-314.

  10. Simó, R., Nixon, I. J., Vander Poorten, V., Quer, M., Shaha, A. R., Sanabria, A., ... & Ferlito, A. (2019). Surgical management of intrathoracic goitres. European Archives of Oto-Rhino-Laryngology276(2), 305-314.

  11. White, M.L., Doherty, G.M., & Gauger, P.G. (2008) Evidence-Based Surgical Management of Substernal Goiter. World J Surg, 32, 1285-1300.

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