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

A Rare Presentation of Thyroid Mass- A case report

Background-Respiratory symptoms are not uncommon in thyroid diseases and can be overlooked and misdiagnosed as acute exacerbation of asthma or COPD. Case report- A 58 years old female presented to emergency department with complaints of fever, shortness of breath from last 3-4 days for which she intubated in emergency department and shifted to ICU. Next day patient was absolutely fine and extubated and was planned to be shifted out surprisingly the same episode was repeated following which patient was intubated again and was found to be absolutely normal after 3-4 h and extubated again. The same episode was repeated next day as well. Eventually she was diagnosed to have cystic thyroid swelling. Immediate aspiration of the cyst done to relieve the symptoms and total thyroidectomy was done subsequently and patient was cured of the symptoms. Conclusion- Acute airway obstruction can occur in asymptomatic goitre patients. The anaesthetic management is crucial for airway till definitive surgery is done.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03179-x.

Clinical Characteristics and Predictors Related to the Progression of Multinodular Goiter Causing Tracheal Compression and Deviation: A Report of Two Cases and Review of the Literature

We describe the clinical course of two patients who developed tracheal compression and deviation by multinodular goiter (MNG). Case 1: A 66-year-old woman presented with thyroid swelling. Five years after the initial admission, she was diagnosed with hyperthyroidism by Graves' disease and increased bilateral thyroid lobes compressing the trachea. Thyroglobulin was elevated from 210 to 472 ng/mL. Case 2: A 52-year-old woman presented with thyroid swelling. Five years after the initial admission, the increased right lobe deviated the trachea and compressed the right recurrent laryngeal nerve. Thyroglobulin was elevated from 122 to 392 ng/mL. Two cases and literature review indicated that MNG with >50 mm, solid components, and extension to the mediastinum or paralarynx were risk factors of tracheal compression and deviation. Monitoring thyroglobulin elevation can help predict the clinical course.

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.

Novel Pulmonary Function Parameter Shifts in High-Grade Upper Airway Stenoses

Upper airway stenosis (UAS) is a common problem for anesthesiologists in laryngology as well as head and neck surgery, but it may lead to life-threatening situations if it is undetected. This retrospective case series was performed on patients who had UAS and presented with severe dyspnea or encountered difficulties in airway management. To assess the severity of UAS, the degree of stenosis was calculated using computed tomography scans and direct endoscopy. Lung function test was collected, and measured values were extracted as percentage of predicted reference values. Lower and higher grade stenoses were defined by Cotton-Myer classification and median degree of stenosis. Median of detected stenoses was 73% (64%-85%), with 7 of 10 patients classified as Cotton-Myer grade 3. Lung function tests showed typical parameter shifts as known from obstructive pulmonary diseases (OPDs). Furthermore, statistical analyses showed a significant higher value of residual volume (RV)/total lung capacity (TLC) in patients with higher grade stenosis (P < .05), whereas forced expiratory volume in 1 second /vital capacity (FEV1/VC) did not show a significant difference in same subgroups. In conclusion, the elevation of RV/TLC with concomitant normal FEV1/VC in symptomatic patients could be used to demarcate rare UAS from common OPD. Moreover, RV-TLC ratio might be used to distinguish between low- and high-grade UAS. But further epidemiological studies will be necessary to validate these findings. Level of evidence: 4.

Acute airway obstruction due to benign multinodular goitre

Benign multinodular goitre is a common illness. When accompanied by obstructive symptoms, such as dyspnoea, it carries an indication for surgery. Benign multinodular goitres rarely cause acute airway obstruction. We report the case of a 88-year-old woman who presented with acute shortness of breath and stridor. A chest CT revealed marked enlargement of the thyroid gland, with an extensive intrathoracic component. She was proposed for total thyroidectomy. Her intraoperative course was unremarkable, but the patient passed away in postoperative period from ventricular fibrillation. Recognition of these cases is important, as they constitute a preventable cause of mortality if timely diagnosed and treated.

Emergent thyroidectomy with sternotomy due to acute respiratory failure with severe thyroid storm

Huge cervical and mediastinal masses may lead to acute respiratory failure caused by laryngotracheal compression and airway obstruction. Thyroid storm is also a life-threatening endocrine emergency originating almost exclusively from uncontrolled Graves' disease. We report a case of a 42-year-old man with acute upper airway obstruction and tachycardia from progressive swelling of a giant thyroid, in conjunction with thyroid storm resulting from uncontrolled Graves' disease. Fibreoptic-assisted nasal intubation was performed while the patient was awake, immediately followed by emergency total thyroidectomy via a cervical and sternal approach. The patient had an uneventful postoperative course and recovered well. Respiratory failure due to swelling of a giant thyroid is a life-threatening condition and should be treated immediately with endotracheal intubation while the patient is awake following emergent total thyroidectomy, even with a sternotomy.