Airway Management in Patients with Tracheal Compression Undergoing Thyroidectomy: A Retrospective Analysis

Airway Management in a Patient with Retrosternal Goiter: A Context-Sensitive Airway Management Strategy

Retrosternal extension of the goiter can cause compression of the trachea, esophagus and major blood vessels. Airway management is indeed a challenge in patients with airway obstructive signs and symptoms and it is based on the severity of the patient's clinical symptoms, availability of airway equipments, familiarity and expertise. We encountered a patient with retrosternal goiter with tracheal compression, presented for surgery required pediatric Fiber-Optic Bronchoscope (FOB) for securing the airway. A 45 year female patient presented with a swelling in front of the neck for 6 months. Recently, she developed intermittent stridor which was aggravated by lying supine. In computed tomography, there was a retrosternal extension of thyroid gland into superior mediastinum causing tracheal compression and narrowing (80%). Awake fiber-optic intubation with paediatric FOB was used to secure the airway before induction of anaesthesia. Paediatric FOB can be useful to secure airway in patients with tracheal compression and narrowing.

Fiberoptic-guided nerve integrity monitoring tube intubation assisted by video-laryngoscope with external laryngeal manipulation in a patient with anteriorly displaced larynx due to huge goiter with retropharyngeal involvement: A case report

RATIONALE

Goiter, an abnormal enlargement of the thyroid gland, can induce airway distortion or tracheal compression. Airway management can be challenging for anesthesiologists, depending on the location and size of the mass as well as the patient's airway conditions, although it is reported that most cases can easily be managed by oral intubation.

PATIENT CONCERNS

A 61-year-old female patient who had planned for a total thyroidectomy due to a huge goiter was intubated with nerve integrity monitoring (NIM) tubes, using video laryngoscopy (VL) and oral fiberoptic bronchoscopy (FOB) alone. The respective attempts initially failed.

DIAGNOSIS

The patient's thyroid mass extended from the C3 cervical spine level to the T1 thoracic spine level with retropharyngeal involvement, causing an upper airway anatomical alteration that made intubation difficult. FOB manipulation was challenging due to the acute angulation of the laryngeal inlet and the tongue and the consequent interruption by the epiglottis. There was resistance to tube introduction, despite counterclockwise rotation of the NIM tube, due to acute angulation of the larynx and circumferential narrowing of the oropharyngeal and supraglottic space.

INTERVENTIONS

In the first step of FOB-guided intubation, external laryngeal manipulation (ELM) was performed to improve the angle of the glottic opening and to elevate epiglottis tip. This allowed for FOB introduction into the trachea. VL was then performed transorally to elevate the tongue base and increase space, using the blade. ELM was applied simultaneously to move the glottis lower, thereby reducing the angle of the tube passage.

OUTCOMES

The NIM tube was successfully introduced into the trachea with counterclockwise rotation in FOB-guided intubation.

LESSONS

The combination of techniques using basic and popular devices and maneuvers, such as ELM and VL, may be useful for the successful management of difficult airways related to retropharyngeal goiter, without the need for surgical airway.

Testing telediagnostic thyroid ultrasound in Peru: a new horizon in expanding access to imaging in rural and underserved areas

PURPOSE

Thyroid ultrasound is a key tool in the evaluation of the thyroid, but billions of people around the world lack access to ultrasound imaging. In this study, we tested an asynchronous telediagnostic ultrasound system operated by individuals without prior ultrasound training which may be used to effectively evaluate the thyroid and improve access to imaging worldwide.

METHODS

The telediagnostic system in this study utilizes volume sweep imaging (VSI), an imaging technique in which the operator scans the target region with simple sweeps of the ultrasound probe based on external body landmarks. Sweeps are recorded and saved as video clips for later interpretation by an expert. Two operators without prior ultrasound experience underwent 8 h of training on the thyroid VSI protocol and the operation of the telemedicine platform. After training, the operators scanned patients at a health center in Lima. Telediagnostic examinations were sent to the United States for remote interpretation. Standard of care thyroid ultrasound was performed by an experienced radiologist at the time of VSI examination to serve as a reference standard.

RESULTS

Novice operators scanned 121 subjects with the thyroid VSI protocol. Of these exams, 88% were rated of excellent image quality showing complete or near complete thyroid visualization. There was 98.3% agreement on thyroid nodule presence between VSI teleultrasound and standard of care ultrasound (Cohen's kappa 0.91, P < 0.0001). VSI measured the thyroid size, on average, within 5 mm compared to standard of care. Readers of VSI were also able to effectively characterize thyroid nodules, and there was no significant difference in measurement of thyroid nodule size (P = 0.74) between VSI and standard of care.

CONCLUSION

Thyroid VSI telediagnostic ultrasound demonstrated both excellent visualization of the thyroid gland and agreement with standard of care thyroid ultrasound for nodules and thyroid size evaluation. This system could be deployed for evaluation of palpable thyroid abnormalities, nodule follow-up, and epidemiological studies to promote global health and improve the availability of diagnostic imaging in underserved communities.

Challenging Airway Management in a Patient with Retrosternal Goiter Presenting in Respiratory Distress

A number of options exist for patients with anticipated difficult intubation on account of a retrosternal goiter compressing on the trachea. The chosen technique(s) to secure the airway in this delicate situation often depends on the location and degree of airway obstruction, available resources/facilities, and an anesthetist's experience and preferences. We report the case of a 68-year-old woman with severe airway obstruction from a retrosternal goiter coming for total thyroidectomy. Airway management started with an awake fiber-optic intubation, proceeded to a tracheostomy and finally to use of a rigid bronchoscope following failure of the earlier techniques to achieve adequate ventilation.

Management of critical tracheal stenosis with a straw sized tube (Tritube): Case report

Imminent upper airway obstruction due to life-threatening tracheal stenosis of any cause is a challenging situation. We present a challenging case of total thyroidectomy for a malignant, invasive, and highly vascularized thyroid carcinoma that has invaded the surrounding tissues, including the sternum and mediastinum, resulting in compression of the trachea with indentation. The patient presented with a significant symptomatic tracheal stenosis, the narrowest area of that was 4 mm. Airway management in such cases presents a particular challenge to the anesthesiologists, especially considering that the option of tracheostomy is very difficult most of the time due to the highly swollen thyroid and distorted anatomy. A meticulous history of the patient's illness had been taken, and a comprehensive preoperative evaluation was conducted, including construction of a 3D model airway, virtual endoscopy, and transnasal tracheoscopy. On the day of the surgery, the airway was managed through spontaneous respiration using intravenous anesthesia and the high-flow nasal oxygen (STRIVE-Hi) technique. It was then secured with intubation using a straw endotracheal tube (Tritube®) with an internal diameter (ID) of 2.4 mm and an outer diameter of 4.4 mm with the help of a fiberscope and D-MAC blade of a video laryngoscope. At the end of the procedure, the airway was checked with a fiber optic scope, which showed an improvement in the narrowed area. This enabled us to replace the Tritube with an adult cuffed ETT of size 6.5 mm ID, and the patient was transferred intubated to the surgical ICU. Two days later, the patient's tracheal diameter was evaluated with the help of a fiberoptic scope and extubated successfully in the operating theater.

Intubation of a Patient with a Large Goiter: The Advantageous Role of Videolaryngoscopy

Fiberoptic bronchoscopy has long been considered the gold standard for patients who present with a difficult airway. In the case presented, a patient has a large palpable goiter and requires intubation. After the unsuccessful attempt to intubate with the use of fiberoptic bronchoscopy, the decision to switch to videolaryngoscopy afforded a positive result. We present this case to suggest that the utilization of videolaryngoscopy may be an alternative option for intubation when other methods have failed. It is imperative for anesthesiologists to understand the benefits that this modality may provide.

Retrosternal Goiter: A couple of classification methods with computed tomograpy findings

Objectives:

The retrosternal goiter (RSG), which can be defined by different classification and its incidence between 2% and 26% of all thyroidectomized patients, is a thyroid gland disease. Our aim was to classify RSG cases with a couple of different ways, which we have detected in computed tomography (CT) imaging of the thorax.

Methods:

In this retrospective study conducted at Kars Harakani State Hospital Pulmonary Medicine Polyclinic between June 2014 and June 2017 in which 176 patients were included. The age, sex, diagnostic codes, retrosternal extension of the thyroid gland (aortic upper arch, aortic reaching arch and aortic inferior arch), extension type (prevascular, paratracheal retrovascular and retrotracheal), extension amount (mm) (<50% and 50%<) of thyroid gland of the patients were assessed.

Results:

About 56.25% (n=99) were female and the mean age was 65.9±11.4 years. The most common co-morbid disease in patients with RSG was Chronic Obstructive Pulmonary Disease (COPD) (52.3%). Thirty nine (22.2%) of the patients had associated nodule, 16 (9.1%) had accompanying tracheal pressure and one patient had nodule and tracheal pressure. 27.3% of the patients’ gland’s right lobe and 28.9% of the patients’ left lobe were extended >50% below the thoracic entry. Left thyroid gland’s (90.3%) retrosternal extension and aortic arch spread (91.2%) were more. When classified according to the trachea, the left lobe’s paratracheal and retrovascular extension (50.9%) was more. Extension amounts were similar for both thyroid lobes.

Conclusion:

In patients who have retrosternal goiter, goiter spread can be defined with multiple classification with thorax CT.