Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review

Silicone stent placement for tracheal stenosis induced by a giant goiter due to Graves' disease: a case report

Background

Although thyroid tumors with tracheal stenosis are occasionally encountered, severe tracheal stenosis caused by benign thyroid tumors is rare. We herein describe a case in which a silicone tracheal stent was placed for severe tracheal stenosis induced by a giant goiter due to Graves' disease.

Case Description

A 93-year-old woman had been receiving thiamazole treatment for Graves' disease with a thyroid goiter for 32 years. She emergently presented to the hospital with sudden difficulty breathing and the temporary loss of consciousness. Although marked stridor was heard, the patient's respiratory status was stable in the first visit. Computed tomography revealed a giant thyroid goiter that extended to the mediastinum. The trachea was compressed by the sternal notch and thyroid gland, resulting in severe stenosis, and the tracheal lumen was only 1 mm. Surgical thyroidectomy was expected to be difficult due to the high risk of complications associated with the large size of the goiter and advanced age of the patient. Therefore, we decided to place a tracheal stent. A silicone stent (Dumon tube®) was inserted into the site of tracheal stenosis under general anesthesia. After stent placement, respiratory distress symptoms improved, and no complications were observed. Three months after stent placement, the stent opening side was narrowed due to defective granulation and, thus, was cauterized with argon plasma coagulation.

Conclusions

We encountered a patient who was treated by tracheal silicone stent placement for severe tracheal stenosis induced by a giant goiter due to Graves' disease. A silicone stent effectively secures the airway for benign thyroid tumors that cause severe airway stenosis.

A new treatment strategy for airway obstruction induced by a giant benign goiter: A case report

Severe respiratory distress induced by airway obstruction requires prompt attention for restoration of normal function in the airway passage. A large benign thyroid goiter that compresses the trachea is a rare occurrence. Emergency thyroidectomy with dyspnea can increase the chance of surgical complications in such cases. Here, a rare case of dyspnea induced by a large goiter is reported and a safe and effective therapeutic strategy for treatment was demonstrated. First, a self-expandable metal stent was placed to relieve airway obstruction. A week later, total thyroidectomy under general anesthesia was performed. After 3 months, the metal stent was surgically removed. The findings of the present case report demonstrated that life-threatening airway obstruction secondary to benign goiter could be effectively treated by placing an airway stent, followed by thyroidectomy.

Difficult airway management and emergency tracheostomy in a patient with giant goiter presenting with respiratory arrest: A case report

Giant goiter is commonly asymptomatic or progresses with nonspecific symptoms, such as pain, hoarseness and dysphagia. In rare cases, enlargement of the thyroid may cause compression of the trachea and lead to life-threatening complications. As a result of iodization programs implemented throughout the world to address iodine deficiency disorders, giant goiter is rare today. Although not common, the disease may result in a difficult airway in cases of tracheal compression. The present study shares our experience of a giant retrosternal goiter in a patient presenting with respiratory arrest who underwent emergency tracheostomy after multiple attempts at orotracheal intubation and then thyroidectomy during an intensive care stay due to the development of tracheomalacia.

Non-Toxic Multinodular Goiter: From Etiopathogenesis to Treatment

Goiter term is generally used for defining the enlargement of thyroid gland. Thyroid nodules are very common and some of these nodules may harbor malignancy. Multinodular goiter (MNG) disease without thyroid dysfunction is defined as non-toxic MNG. There are many factors in etiology for development of MNG. They can be classified as iodine dependent and non-iodine dependent factors basically. Beyond this basic classification, the effect of many environmental and acquired factors is also effective on the development of goiter. Many methods have described for diagnosis and treatment for non-toxic MNG. Biochemical tests, imagining methods, invasive and non-invasive methods have been used for diagnosis for many years. Each method has advantages and disadvantages, separately. Although the best method for diagnosis is still debatable, distinguishing malignant nodules from benign nodules is the first and most important step for MNG. Biochemical tests such as serum thyroid stimulating hormone (TSH) measurement, thyroid hormone measurement; and thyroid ultrasonography are used for diagnosis of MNG, traditionally. Nowadays, there are some new techniques were developed like ultrasound-elastography. Furthermore, thyroid scintigraphy may be used if there is abnormal TSH measurement. Fine-needle aspiration biopsy and some cross-sectional imaging methods (computed tomography, magnetic resonance imaging, and positron emission tomography) could be used, too. After a certain diagnosis is made, treatment options should be evaluated. Many treatment methods have been used for goiter from ancient times upon today. From non-invasive methods such as medical follow-up to invasive methods such as lobectomy or thyroidectomy are options for treatment. Patients with compression symptoms due to an enlarged thyroid gland are usually candidates for surgery. In this study, it is aimed to determine the most appropriate treatment for the patient by discussing the advantages and disadvantages of all these methods. The present review discusses definition of goiter term, etiology, epidemiology, pathogenesis, diagnostic methods, and treatment methods for nontoxic MNG.

Spontaneous Thyroid Hemorrhage Caused by Langerhans Cell Histiocytosis: A Case Report and Literature Review

PURPOSE

Langerhans cell histiocytosis (LCH) is a rare clonal disorder of Langerhans antigen-presenting cells. However, thyroid LCH involvement is relatively rare. We present the first case of spontaneous thyroid hemorrhage due to LCH progression and discuss the clinical features, diagnosis, and treatments of thyroid LCH in a literature review.

METHODS

Clinical data were collected. Previously published articles on thyroid LCH involvement were reviewed to assess the clinical features, diagnosis, and treatments for thyroid LCH.

RESULTS

A 54-year-old female presented with a multi-system LCH, affecting the uterus, liver, pituitary gland, and thyroid gland. Clinical stability was achieved after systemic chemotherapy. After 7 years of regular follow up, the patient complained of a sudden painful neck swelling and progressive dyspnea. Computed Tomography revealed bilateral goiter with hematoma, and the patient was diagnosed with spontaneous thyroid bleeding based on her clinical symptoms and radiological findings. The patient was incubated to relieve airway compromise and partial thyroidectomy was performed for definitive treatment. Pathological evaluation further confirmed the diagnosis of thyroid LCH. The patient recovered well after surgery.

CONCLUSION

Spontaneous thyroid bleeding due to thyroid LCH progression is extremely rare. Treatments for LCH vary depending on the severity of the disease. We suggest that, for patients with multi-system LCH with thyroid lesion, long-term active surveillance of thyroid hormone concentrations, and thyroid gland volume is required. Physicians should be alert of the potentially life-threatening spontaneous thyroid hemorrhage when aggravated diffuse goiter and hypothyroidism appear. Further investigation is required to establish the guidelines for thyroid LCH treatment.

Determining the Thyroid Gland Volume Causing Tracheal Compression: A Semiautomated 3D CT Volumetry Study

Background and objectives: Increased thyroid gland volume (TV) may bring about tracheal compression, which is one of the causes of respiratory distress. The aim of this study was to investigate the relationship between TV and the severity of tracheal compression independent of patients’ symptoms using semiautomated three-dimensional (3D) volumetry (S3DV) reconstructed from computed tomography (CT) scans. Cut-off TVs leading to different levels of tracheal narrowing were evaluated. Materials and Methods: One hundred sixty-three contrast-enhanced head and neck CT examinations were retrospectively assessed. TVs were measured by S3DV. The degree of tracheal compression was measured at the point where the greatest percent reduction in the cross-sectional area of the trachea adjacent to the thyroid gland was observed. To determine the severity of compression, the tracheal compression ratio (TCR) was defined (TCR = A1 (the narrowest cross-sectional area of trachea)/A2 (the largest cross-sectional area of trachea)). Results: The mean tracheal narrowing was 15% (TCR = 0.85 ± 0.15) in the study population. Patients with more than 15% tracheal compression had significantly higher TV values than those with less than 15% tracheal compression (p < 0.001). In addition, a significant correlation was found between TV and tracheal compression (p < 0.001). Moreover, the receiver operating characteristic (ROC) curve analysis revealed that the cut-off levels for TV that predict a tracheal narrowing of 10%, 20%, 30%, and 40% were 19.75 mL, 21.56 mL, 24.54 mL, and 30.29 mL, respectively (p < 0.05). Conclusions: This study objectively demonstrated that larger thyroid glands cause more severe compression on the trachea. The results may be helpful during the decision-making process for thyroidectomies to be performed due to compression symptoms.

Multinodular Goiter Spontaneous Hemorrhage in ESRD Patients Result in Acute Respiratory Failure: A Case Report

Euthyroid multinodular goiters may lead to acute respiratory failure caused by airway obstruction or laryngotracheal compression. Here, we present a case admitted to the nephrologist with multinodular goiter spontaneous hemorrhage along with respiratory failure and end-stage renal disease (ESRD), which required urgent surgical intervention.We report the case of a 63-year-old woman with ESRD who presented with a rapidly enlarging nodular goiter resulting in acute respiratory failure. Endotracheal intubation and emergency partial thyroidectomy were performed, revealing multinodular goiter spontaneous hemorrhage by postoperative histopathology. Several cases of benign goiters necessitating endotracheal intubation have been reported. Goiters are among the rare diagnoses in patients consulting at our institution's Nephrology.This case illustrates that ESRD patients with benign goiter may lead to acute respiratory failure due to airway obstruction or laryngotracheal compression. It was found in agreement with previous reports. This case highlights that ESRD patient at risk of this life threatening complication such as multinodular goiter hemorrhage should be managed with elective thyroidectomy to reduce morbidity and mortality.

Anaesthesia for goitre surgery: A review

Goitres are relatively common and, in extreme cases, present unique challenges (particularly in airway management) for the anaesthetist. There are no specific guidelines from the Difficult Airway Society (United Kingdom) or the American Society of Anesthesiologists for the management of the obstructed airway. We therefore present the principles governing the provision of safe anaesthesia for goitre surgery including formulating a plan ABC for patients with a stable airway and for those presenting with acute airway obstruction.

Acute airway obstruction due to spontaneous intrathyroid hemorrhage precipitated by anticoagulation therapy

Acute airway compromise due to hemorrhage in of thyroid gland is a rare life-hreating condition. The increasing use of anticoagulants for various reasons is likely increased the occurrence of this this complication. We describe an elderly patient on anticoagulation for atrial fibrillation, which developed swelling on the right side of neck causing acute airway obstruction requiring emergency intubation for airway protection. Computed tomographic scan showed massive intrathyroid hemorrhage along with substernal extension. She had supratherapeutic INR which was appropriately corrected emergently. She underwent resection of the thyroid gland which showed multinodular goiter without any evidence of malignancy. Our case illustrates the rare but lethal bleeding complication of anticoagulants in critical anatomical area and we request physicians should be wary of similar conditions.

Emergency thyroidectomy: Due to acute respiratory failure

•

CT scan has a great value for retrosternally extended giant goiter cases.

•

If the general status of the patient prevents CT scan, bedside ultrasound can be used instead.

•

Nasal awake intubiation is an appropriate choice for the patients with destructed trachea.

•

Emergency thyroidectomy is a common option for the treatment of giant goiter causing airway obstruction.

INTRODUCTION

Giant cervical and mediastinal goiter may lead to acute respiratory failure caused by laryngotracheal compression and airway obstruction. Here, we present a case admitted to the emergency service with a giant goiter along with respiratory failure and poor general health status, which required urgent surgical intervention.

PRESENTATION OF CASE

A 71-year-old female admitted to the emergency room with shortness of breath and poor general health status resulting from a giant cervical swelling progressively increased during the last 7 years and constituted severe respiratory failure which has become severe in the last one month. A giant nodular goiter of the left thyroid lobe extending retrosternally, causing tracheal compression, limiting the neck movements was detected with clinical examination and bedside ultrasound. Emergency thyroidectomy was planned. Fiberoptic-assisted awake nasal intubation was performed in the operating room. Emergency total thyroidectomy was performed for the life-threatening respiratory failure. Postoperative period was uneventful. She was transferred from intensive care unit to the ward on postoperative day 3 and was discharged from the hospital on the postoperative 7th day. Benign multinodular hyperplasia was reported on the histopathological report. Patient was included in routine follow-up.

DISCUSSION

In the present case tracheal destruction due to compression of the giant goiter was found in agreement with previous reports. Emergency thyroidectomy was performed after awake intubation since it is a common surgical option for the treatment of giant goiter causing severe airway obstruction.

CONCLUSION

Respiratory failure due to giant nodular goiter is a life-threatening situation and should be treated immediately by performing awake endotracheal intubation following emergency total thyroidectomy.

Management of airway compromise following thyroid cyst hemorrhage after thrombolytic therapy

The risk of hemorrhage after therapeutic administration of tissue plasminogen activator (tPA) is well known. Cases of postadministration hemorrhage have been reported within many organ systems. We present a case of a 62-year-old female with undiagnosed thyroid goiter who received tPA for acute ischemic stroke and developed acute airway compromise. The surgical airway response team was called due to inability to ventilate or intubate. An incision into the mass during attempted tracheotomy released colloid and blood, decompressing the airway and facilitating ventilation and intubation. Hemithyroidectomy for mass removal was delayed for 3 days to allow normalization of post-tPA coagulopathy.

Acute respiratory failure in a rapidly enlarging benign cervical goitre

Benign goitres have the potential to reach massive sizes if neglected, but most have a protracted course that may or may not present with compressive symptoms. We report the case of a 57-year-old man who presented with a rapidly enlarging nodular goitre resulting in acute respiratory failure. Endotracheal intubation and emergency total thyroidectomy were performed, revealing massive thyroid nodules with minimal intrathoracic extension and tracheal erosion. Despite a course and clinical findings suggestive of malignant disease, histopathology was consistent with a benign multinodular goitre. Several cases of benign goitres necessitating endotracheal intubation have been reported. Airway compromise was attributed to a significant intrathoracic component, or inciting events such as thyroid haemorrhage, pregnancy, radioiodine uptake or major surgery. Obstructive symptoms may not correlate well with objective measures of upper airway obstruction such as radiographs or flow volume loops.