Tracheal collapse after thyroidectomy

Anaesthesia for thyroid surgery: perioperative management

The aim of this review is to analyse anaesthesiologic preoperative assessment, intraoperative management and postoperative complications of patients with thyroid disease. A special care is paid to difficult airway recognition and resolving this situation. Anaesthetist's and surgeon's point of view of perioperative and postoperative complications is both discussed with special interest on early surgical complications and the need for urgent anaesthetic treatment. Particularly total intravenous anaesthesia and recurrent laryngeal nerve monitoring actually are two end-points in the thyroid surgery.

Results of surgical treatment in multinodular goiter with an intrathoracic component

PURPOSE

(1) To determine the clinical profile of intrathoracic multinodular goiter (IMG); (2) to evaluate the results of surgery, and (3) to analyze the incidence of malignancy and its evolution.

METHODS

Two hundred and forty-seven operated cases of IMG were reviewed. These cases of IMG had all been diagnosed according to Eschapse's definition (>3cm below the sternal manubrium). The morbidity and postoperative evolution were analyzed. A comparative study was carried out on a group of 425 cases of nonintrathoracic goiter. We applied the chi(2) test, Student's t-test, and a logistical regression analysis.

RESULTS

Intrathoracic MG occurs in patients over 60 years of age, with goiter which has a long evolution time (>12 years), and more than 60% are symptomatic. Oral tracheal intubation was difficult in 10% (n = 24) of the cases, and 7 required the use of a fibrobronchoscope. In 8 cases (3%) a thoracic approach was necessary. Morbidity occurred in 24% (n = 59), most notably 29 recurring lesions (12%), of which 2 were definitive (0.8%), and 31 hypoparathyroidisms (13%), of which 1 was definitive (0.4%). No significant difference was found in the postsurgical morbidity between the intrathoracic MG and the nonintrathoracic cases. Regarding the remission of the symptoms, the results were excellent. In 14 cases (5.7%) thyroid carcinoma was related with, most of these being papillary microcarcinoma. In 10 of the 49 cases of partial surgery (20%) a relapse of the goiter was observed.

CONCLUSIONS

Intrathoracic MG is usually asymptomatic and it occurs in goiter with a long time of evolution. Surgery is a good therapeutic option given that the goiter can be removed via the neck, with low morbidity, a remission of the symptoms, malignancy is ruled out, and recurrence can be avoided if a total thyroidectomy is performed.

High Incidence of Tracheomalacia in Longstanding Goiters: Experience from an Endemic Goiter Region

BACKGROUND

Our institute caters to a large number of patients with large, longstanding multinodular goiters; tracheal deviation and resulting airway problems like tracheomalacia are relatively common. However, the literature is sparse on the criteria of early diagnosis and optimum management of tracheomalacia, which our study highlights.

METHODS

This retrospective study analyzed 900 thyroidectomies carried out during 1990-2005 for which data from 28 patients treated for tracheomalacia after thyroidectomy were available for analysis. Criteria for making a diagnosis of tracheomalacia after thyroidectomy included one or more of the following: normal vocal cord mobility, absence of glottic or subglottic edema or hematoma, soft and floppy trachea on palpation, obstruction to spontaneous respiration on gradual withdrawal of the endotracheal tube.

RESULTS

Mean duration of thyroid enlargement was 13.75 years. Only 7 patients had a history of stridor. Tracheostomy was performed in 26 patients, and 2 patients were put on prolonged intubation. Tracheostomy was performed in 18 patients on the operating table, and 8 in the recovery room. The mean weight of the gland was 442 g and histopathology revealed that 11 cases were benign goiter. The tracheostomy tube was removed after an average of 8.5 days. There were no cases of tracheal stenosis on long-term follow-up.

CONCLUSIONS

Patients with longstanding goiter, even when benign, are more prone to develop tracheomalacia. On the basis of our experience we strongly advocate tracheostomy intraoperatively if the trachea is soft and floppy and/or collapse of the trachea is observed following gradual withdrawal of the endotracheal tube.

Acute airway obstruction in the puerperium secondary to massive thyroid enlargement

Pregnancy is known to be thyrogenic and may exacerbate features of thyroid disease. We report the case of a patient whose pregnancy was complicated by respiratory symptoms following remarkable increase in size of a pre-existing goitre. She declined surgery during the pregnancy and it was rescheduled for after the puerperium. A week postpartum she developed acute airway obstruction which necessitated urgent thyroidectomy and management of tracheomalacia with a tracheostomy postoperatively. The effect of pregnancy on the course of her disease and the anaesthetic challenges in the face of limited airway equipment are highlighted.

Intrathoracic goiter: analysis of 21 cases

Goiters are classified into: the cervical, retrosternal, substernal and intrathoracic. The aim of research is to analysis of intrathoracic goiters (ITG) which include goiters with more than 80% of tissue in the thoracic cavity and intrathoracic thyroid choristomas.

METHODS

In prospective non-randomized study were analyzed 21 consecutive patients operated on for intrathoracic non-toxic benign goiters from 1987-98. Fourteen patients with intrathoracic goiters (more than 80% of tissue in the thoracic cavity) and seven patients with intratoracic choristomas were operated. Two groups of ITG were observed according to the expressed symptomatology and surgical approach and complications of operative treatment were compared to the complications of operative treatment of 986 non-ITG non-toxic benign goiters.

RESULTS

ITG represented 1.1% of the whole number of operatively treated thyroid diseases. One third of patients were asymptomatic. Commonly observed symptoms were dispnea, stridor and dysphagia and there was no significant difference in appearance of these symptoms between the two groups of ITG. In 19% of patients correct preoperative diagnosis wasn't assessed. Cervical approach with sternothomy was used in 11 patients, cervical approach with right thoracotomy in seven, right thoracotomy only in two, and cervical approach only in one patient. Thoracic approach was used in 95% of cases and there was no significant difference between the two groups of ITG. Concerning the operative complications, in two patients transient vocal cord paresis and in one patient postoperative bleeding were verified. There was no statistically significant deference in frequency of operative complications between ITG and non-ITG.

CONCLUSIONS

ITG are rare, but might present a difficult diagnostic and complex surgical problem. Common clinical presentation and identical surgical approach in operative treatment justify the common review of the two groups of intrathoracic goiters. With adequate and timely performed surgical approach, in specialized institutions, frequency of complications in operative treatment of ITG is not higher if compared to operative treatment of non-ITG.

Papillary thyroid carcinoma in intrathoracic goiter

Intrathoracic goiter (more than 80% of tissue in the thoracic cavity) represents very rare clinical entity (less than 1% of total number of thyroid gland surgical procedures). Cancer incidence in these goiter is 0-5%. The aim of this article is to present a case report of intrathoracic thyroid papillary carcinoma with multiple compressive syndrome and review of compressive intrathoracic syndrome of thyroid etiology. In our patient we have found: tracheal and oesophageal deviation and compression, superior vena cava syndrome, downhill varices, chylothorax, pericardial effusion, compress of the left a. subclavia, unilateral lesion of recurrent and phrenic nerve, and brachial plexopathy. This was a unique case with multiple compressive syndrome between 3000 patients surgically treated for all kinds of thyroid deceases. Intrathoracic goiter can cause all the known symptoms and syndromes of intrathoracic compression with possibility of rapid deterioration and fatal end.

Thyroid disease

In summary, disease of the thyroid gland is common. Anaesthetists will be required to manage patients with hypothyroidism and hyperthyroidism and those requiring thyroidectomy. Since anaesthesia for thyroidectomy provides many challenges of airway management, the anaesthetist should pay particular attention to preoperative assessment of the airway and should be able to deal with acute airway complications in the perioperative phase.

The management of benign thyroid goitre causing tracheo-oesophageal embarrassment

The case of a massive benign thyroid goitre extending from the arch of aorta to the nasopharynx presenting with acute aerodigestive obstruction is reported. The management of the case is discussed and also a review of the relevant literature.

Tracheal occlusion in the prone position in an intubated patient with Duchenne muscular dystrophy

A 15-year-old boy with Duchenne muscular dystrophy developed complete airway obstruction under general anaesthesia when positioned prone for spinal surgery. Tracheobronchial compression against vertebral bodies facilitated by a shortened sternovertebral distance due to thoracic lordoscoliosis is suggested as the cause.

Substernal goiter: a clinical review

Thyroid disease is a very common problem, but indications for surgery are few. We have seen a large number of patients with multinodular goiter. The main indications for surgery in thyroid disease include fear of malignancy, tracheo-esophageal compression, and cosmetic reasons. Tracheo-esophageal compression is most commonly noted in patients with mediastinal goiters. Substernal goiter is defined as those situations in which at least 50% of the gland is in the mediastinal location. Although its incidence has decreased, it remains prevalent in almost every country in the world today. SSG is best diagnosed by a thorough history and physical examination, complemented by airway films, fiberoptic laryngoscopy, and computerized tomography. The most common presenting symptoms are those produced secondary to compression effects. SSG show a poor response to medical treatment. Moreover, given their propensity to cause acute airway symptoms, surgical treatment should be considered in most cases. Extirpation of the gland is best performed through a collar incision, with the addition of a median sternotomy in select few and difficult cases. Median sternotomy is necessary in only 1% to 2% of cases. Operative mortality is negligible, and the incidence of complication is minimized by following strict surgical principles.

Airway complications in thyroid surgery

Perioperative and postoperative morbidity and mortality were studied in a series of 3,008 thyroidectomies. Compressive symptoms, frequent in substernal and cancerous goiters, were present in 11.0% of the patients, although a low rate of dyspnea (2.7%) was observed. In large goiters, some orotracheal intubations were difficult. In such cases, the transtracheal approach can also be difficult, so failure should be anticipated. Postoperative causes of respiratory obstruction included local hemorrhages, bilateral recurrent nerve palsies, and laryngeal edema. A tracheal collapse was not observed. These respiratory obstructions led to repeat surgery in 11 patients, tracheostomy in 3, and temporary reintubation with steroid therapy in 1. The recurrent laryngeal nerve, which may have been affected preoperatively, was found to be damaged postoperatively in 0.5% of the patients with benign goiters, compared to 10.6% of the patients with thyroid cancer. In this last group a bilateral palsy was observed in 3 cases with prolonged or extensive surgery. After these short-term orotracheal intubations (114 minutes on average), injuries of the airway caused by the endotracheal tube were found in 4.6% of the patients.

An experimental model for the surgical correction of tracheomalacia

Tracheomalacia may result from large intrathoracic goiters. Due to the chronic compression, particularly within the confines of the thoracic inlet, the tracheal wall weakens, with disintegration of some of the cartilaginous rings. Tracheomalacia can cause acute airway distress, particularly during the post-operative period, and may occasionally result in death. The other major cause of tracheomalacia is related to either prolonged endotracheal intubation or over-inflation of the tracheostomy cuff. While various techniques such as internal stenting, external support devices, tracheostomy, and tracheal resection have been used based on individual circumstances, no one method appears to be perfect. To further study this difficult problem, an experimental model of tracheomalacia was created in eight dogs. Six to seven rings of the tracheal cartilages were dissected submucosally. More than half of the circumference of the tracheal rings was resected. The tracheal walls were reconstructed with polytetrafluoroethylene (PTFE) grafts. The grafts strengthened the tracheal wall without causing luminal constriction. Tracheostomy was not performed on any of the dogs. All dogs tolerated the procedure well and were extubated at the conclusion of the experiment. The dogs were followed for 4 to 6 months and then sacrificed so that the tracheal wall could be examined histologically. There was considerable fibrosis leading to stiff neotrachea. The results of this experimental technique for prosthetic reconstruction to counteract problems simulating tracheomalacia are very encouraging.

Airway obstruction due to goiter in older patients

It has been shown that goiters can progressively enlarge to compress the surrounding trachea or esophagus and result in incapacitating obstructive symptoms or potentially fatal airway obstruction. The potential of a goiter to become hyperactive also exists. Recently, we have seen three older patients with longstanding untreated "benign" goiters who presented difficult management decisions. Given the likelihood of progressive growth of a goiter and the increased life expectancy of these patients with goiters, it is essential to perform flow-volume loop studies while following these patients.

Goiters and airway problems

Even though thyroid enlargement occurs commonly, the incidence of goiter has decreased in the United States due to the routine use of iodized salt. We continue to see a large number of patients with neglected goiters that cause airway compression. The progressive nature of this disease occasionally results in severe tracheal compression and acute airway distress. We treated 120 patients with airway compression secondary to goiters during a 7-year period. Thirty patients presented initially with acute airway distress requiring either intubation or semiemergent surgery. The decision to operate was based primarily on clinical evaluation and airway films. Ninety patients had substernal goiters. Only one patient required sternal splitting. If one lobe was enlarged causing tracheal deviation, lobectomy was performed; if both lobes were enlarged, subtotal thyroidectomy was performed. Two patients required tracheostomy. There were no operative deaths, and morbidity was limited to minor wound problems. It is important to consider early surgical decompression whenever tracheal compression is caused by goiters, especially if the patients are symptomatic or there is mediastinal extension.

Endotracheal intubation following thyroidectomy

Thirty-five patients requiring tracheostomy or endotracheal intubation, following thyroidectomy are reviewed. Conditions included 30 patients with multinodular goitre, three patients with Graves's disease and two patients with carcinoma of the thyroid. Early in the series, emergency tracheostomy was performed in three patients with airway obstruction following thyroidectomy. Ten patients were deemed at extremely high risk of developing airway obstruction and underwent prophylactic tracheostomy. Endotracheal intubation has been used in preference to tracheostomy in the latter part of the series. Emergency endoctracheal intubation was performed on one patient and prophylactic intubation was carried out in 20 patients. The morbidity and length of hospital stay in this latter group was considerably less than those requiring tracheostomy. It is concluded that patients with potential airway obstruction following thyroidectomy should have prophylactic endotracheal intubation, in preference to tracheostomy.

Management of substernal and intrathoracic goiters

Goiters that descend into the mediastinum can cause respiratory embarrassment, dysphagia, vascular compression, vocal cord paralysis, and sudden death. Although many such goiters remain clinically silent, their ability to produce sudden and unpredictable respiratory distress is well known. The condition was not considered uncommon in the first half of the twentieth century; some authors reported series of hundreds of thyroidectomies for intrathoracic goiter. Though seen less frequently today, the only effective treatment for mediastinal goiter is surgical removal. We report our experience with the management of 70 consecutive patients with substernal or intrathoracic goiters. The clinical presentation, preoperative evaluation, operative technique, and results and complications of therapy are discussed. Consideration is also given to the pathogenesis of intrathoracic extension. The transcervical approach for resection is emphasized--even goiters extending to the aortic arch were safely removed without requiring sternotomy. A multidisciplinary team approach, including the surgeon, anesthesiologist, and endocrinologist, is essential. Because of more conservative trends in the selection of patients for thyroidectomy, the incidence of mediastinal goiter may be increasing.

Substernal goiter

The literature on substernal goiter from the seventeenth century to the present is reviewed. Substernal goiter may be defined as any thyroid enlargement that has its greater mass inferior to the thoracic inlet. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. Patients are generally in the fifth decade of life, and women predominate. Most patients experience dyspnea, stridor, or dysphagia, but 15 to 50% are asymptomatic; symptoms are often positional, and acute stridor may occur. Ten to twenty percent have no cervical mass or tracheal deviation on examination, and virtually all patients are euthyroid. Standard chest roentgenograms are often diagnostic, but computed tomographic or radioactive iodine scans may be helpful. The presence of a substernal goiter in all but the highest-risk patients is an indication for resection, usually through a cervical collar incision; an occasional patient will require sternotomy or thoracotomy. Death or major complications should be rare postoperatively. Substernal goiters are adenomatous and benign, but carcinoma occurs in 2 to 3% and may be occult. Patients should be followed closely, as these goiters may recur.