Tracheomalacia after reoperation for an adenomatous goiter located in a unique position

Tracheomalacia after thyroidectomy for retrosternal goitres requiring sternotomy- a myth or reality?

INTRODUCTION

Tracheomalacia after thyroidectomy is not well understood. Reports on tracheomalacia are conflicting, with some suggesting a high rate and other large cohorts in which no tracheomalacia is reported. The aim of our study was to assess the incidence and factors associated with tracheomalacia after thyroidectomy in patients with retrosternal goitres requiring sternotomy at a high-volume tertiary care referral centre.

METHODS

A longitudinal cohort study was conducted from January 2011 to December 2019. All adult patients who underwent thyroidectomy with sternotomy were included. Tracheomalacia was considered when tracheal rings were soft compared with other parts (proximal or distal) of the trachea and required either tracheostomy or resection with anastomosis. The decision to perform a tracheostomy or to administer continuous or bilevel positive airway pressure postoperatively was made depending on the degree of tracheomalacia. Logistic regression analysis was used to assess factors associated with tracheomalacia.

RESULTS

We evaluated 40 patients who underwent thyroidectomy with sternotomy. The mean age of our cohort was 48.7 ± 11.3 years and the population was predominantly female (67.5%). One patient required tracheal resection with anastomosis, and two patients required tracheostomy. Multivariable logistic regression analysis did not reveal any patient- or thyroid-related factor significantly associated with the development of tracheomalacia in our cohort.

CONCLUSIONS

The incidence of tracheomalacia after thyroidectomy with sternotomy appears to be very low. However, the occurrence of tracheomalacia after thyroidectomy in cases of large goitre is possible and hence worrisome.

Redo thyroid surgery without drains

PURPOSE

Redo thyroid surgery is associated with higher risk of hematoma than the initial thyroid surgery. We report a single surgeon's experience of performing redo thyroid surgery without drains.

METHODS

This retrospective single-institutional study evaluates the safety and efficiency of redo thyroid surgery without drains by comparing three groups of patients: those who underwent primary bilateral thyroidectomy (Group 1), those who underwent completion thyroidectomy (Group 2); and those who underwent thyroidectomy for recurrent thyroid diseases (Group 3).

RESULTS

The demographic characteristics did not differ among the groups. Substernal extension and hyperthyroidism were more frequent in group 1, whereas the weight of the resected thyroid gland was lower in groups 2 and 3. Hematoma occurred in 5%, 4%, and 4% of patients in Groups 1, 2, and 3, respectively. Postoperative transient hypocalcemia occurred in 19%, 16%, and 21% of patients in Groups 1, 2, and 3 respectively. The postoperative incidence of transient recurrent laryngeal nerve (RLN) paralysis in Groups 1, 2, and 3, was 6%, 7%, and 8%, respectively. The incidence of permanent unilateral RLN paralysis in Groups 2 and 3 was 1%. The postoperative length of stay was 1 day in 92% of the patients from all groups.

CONCLUSIONS

Avoiding the routine use of drains in redo thyroid surgery is safe and effective, it does not increase overall surgical morbidity, and it reduces the overall length of stay in hospital.

Thyroidectomy Improves Tracheal Anatomy and Airflow in Patients with Nodular Goiter: A Prospective Cohort Study

OBJECTIVE

A large goiter may cause compression of the trachea. The aim of this study was to investigate the impact of thyroidectomy on tracheal anatomy and airflow and to correlate this with changes in health-related quality of life (HRQoL) in patients with benign nodular goiter.

METHODS

Magnetic resonance images of the neck and respiratory flow-volume curves, including both inspiration and expiration, were performed prior to and 6 months following surgery. HRQoL was measured by selected scales from the thyroid-specific patient-reported outcome (ThyPRO). Cohen's effect size (ES) was calculated as mean change divided by standard deviation at baseline. ES of 0.2-0.5 were defined as small, 0.5-0.8 as moderate, and values >0.8 as large.

RESULTS

Sixty-five patients completed all examinations. Median goiter volume was 58 mL (range, 14-642 mL) before surgery with surgical removal of a median of 43 g (range, 8-607 g). Six months after surgery, tracheal narrowing and deviation were diminished by a median of 26% (ES = 0.67, p < 0.001) and 33% (ES = 0.61, p < 0.001), respectively. Correspondingly, each 10% decrease in goiter volume resulted in 1.0% less tracheal narrowing (p < 0.001). Concomitantly, a small improvement was seen in forced inspiratory flow at 50% of forced vital capacity (ES = 0.32, p < 0.001). A reduction in tracheal narrowing was associated with improvements in the Impaired Daily Life scale (0.33 points per 1% decrease in tracheal narrowing, p = 0.03) of the ThyPRO questionnaire.

CONCLUSIONS

In patients with symptomatic benign nodular goiter, thyroidectomy resulted in substantial improvements in tracheal anatomy and improvements in inspiratory flow, which were followed by gains in HRQoL. This information is pertinent when counseling patients before choice of treatment.

[The laryngeal condition in the patients presenting with euthyroid multinodular goiter as evaluated by direct laryngoscopy]

The objective of the present study was to improve diagnostics of disturbances in the laryngeal condition of the patients presenting with euthyroid multinodular goiter with special reference to the condition of the upper respiratory passages. The preoperative characteristic of 398 patients included the description of the predominant clinical syndrome (the neoplastic and compressive variants) and specification of the morphological type of the disease to promote the decrease of operative activity with respect to colloidal proliferative goiter. Direct laryngoscopy was employed in addition to the traditional diagnostic techniques during both the surgical operation and the follow-up observation. Hoarseness developed in the postoperative period in 13.4% to 16.9% of the patients. Postoperative transient and persistent laryngeal paresis was documented in 1.5% and from 1.5% to 4.2% of the cases respectively. Direct laryngoscopy revealed the symptoms of laryngitis and laryngotracheitis as well as foci of leukoplakia, laryngeal cysts and nodules, besides disturbances in the mobility of the vocal chordae. It is concluded that the above pathological changes in the laryngeal structures should be identified during the preoperative examination of the patients presenting with euthyroid multinodular goiter while direct laryngoscopy must be included in the program of postoperative supervision.

Acute airway obstruction due to benign asymptomatic nodular goiter in the cervical region: A case report

Benign nodular goiter is a common disease. Although large goiters with obstructive symptoms including shortness of breath and dyspnea are a clear indication for surgery, acute upper airway obstruction, particularly in benign cervical goiter cases, is rare. We herein report the case of 46-year-old female with acute upper airway obstruction due to benign nodular goiter. The patient had a large and elastic goiter which was more pronounced on the left side of her neck, and surgery was scheduled for within a few months. Three months after the initial presentation, while still waiting for surgery, the patient was brought to the emergency room due to loss of consciousness and breathing difficulty and was immediately intubated. A computed tomography (CT) scan revealed that the trachea was markedly compressed by a nodular lesion in the left lobe, and bilateral pneumonia was also evident. Total thyroidectomy was immediately performed via the supraclavicular approach. The patient had an uneventful postoperative course and recovered well. The resected specimen included a well-encapsulated solid and cystic mass. Histopathological examination mainly revealed adenomatous goiter. The present case suggests that benign asymptomatic nodular goiter mostly located in the neck may cause acute airway obstruction, even if the nodules are not large. Early surgery should be performed when tracheal deviation and stenosis due to a large goiter is prominent by CT scan.