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Mahajan S, L S, Kumar S. Airway Management in a Patient with Retrosternal Goiter: A Context-Sensitive Airway Management Strategy. Indian J Otolaryngol Head Neck Surg 2022; 74:2214-2216. [PMID: 36452762 PMCID: PMC9701988 DOI: 10.1007/s12070-020-02083-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022] Open
Abstract
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.
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Affiliation(s)
- Shalvi Mahajan
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012 India
| | - Sekar L
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012 India
| | - Sanjay Kumar
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012 India
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Kim JY, Yeom JY, Youn SJ, Lee JE, Oh JY, Byun SH. 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. Medicine (Baltimore) 2022; 101:e29041. [PMID: 35451415 PMCID: PMC8913080 DOI: 10.1097/md.0000000000029041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/23/2022] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Ji-Yoon Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Ji-Yong Yeom
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Si-Jeong Youn
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jeong-Eun Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jin-Young Oh
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sung-Hye Byun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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Marini TJ, Weiss SL, Gupta A, Zhao YT, Baran TM, Garra B, Shafiq I, Oppenheimer DC, Egoavil MS, Ortega RL, Quinn RA, Kan J, Dozier AM, Tamayo L, Carlotto C, Castaneda B. Testing telediagnostic thyroid ultrasound in Peru: a new horizon in expanding access to imaging in rural and underserved areas. J Endocrinol Invest 2021; 44:2699-2708. [PMID: 33970434 PMCID: PMC8572222 DOI: 10.1007/s40618-021-01584-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/21/2021] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- T J Marini
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - S L Weiss
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - A Gupta
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - Y T Zhao
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - T M Baran
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - B Garra
- Medical Imaging Ministries of the Americas, 10810 Lake Minneola Shores, Clermont, FL, 34711, USA
| | - I Shafiq
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - D C Oppenheimer
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - M S Egoavil
- Medical Innovation and Technology, Calle Los Libertadores 635, 15046, San Isidro, Peru
| | - R L Ortega
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - R A Quinn
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - J Kan
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - A M Dozier
- University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY, 14642, USA
| | - L Tamayo
- Medical Innovation and Technology, Calle Los Libertadores 635, 15046, San Isidro, Peru
| | - C Carlotto
- Medical Innovation and Technology, Calle Los Libertadores 635, 15046, San Isidro, Peru
| | - B Castaneda
- Pontifica Universidad Catolica del Peru, Av. Universitaria 1801, 15088, San Miguel, Peru.
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Osinaike BB, Ogunsiji AO, Joseph OC. Challenging Airway Management in a Patient with Retrosternal Goiter Presenting in Respiratory Distress. Niger J Surg 2021; 27:66-70. [PMID: 34012246 PMCID: PMC8112356 DOI: 10.4103/njs.njs_58_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/24/2020] [Accepted: 03/26/2020] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Babatunde B Osinaike
- Department of Anaesthesia, University of Ibadan/University College Hospital, Ibadan, Nigeria
| | - Alaba O Ogunsiji
- Department of Anaesthesia, University College Hospital, Ibadan, Nigeria
| | - Olufunke C Joseph
- Department of Anaesthesia, University College Hospital, Ibadan, Nigeria
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Shallik N, Elarref M, Khamash O, Abdelaal A, Radi Alkhafaji M, Makki H, Abusabeib A, Moustafa A, Menon A. Management of critical tracheal stenosis with a straw sized tube (Tritube): Case report. Qatar Med J 2021; 2020:48. [PMID: 33598418 PMCID: PMC7842837 DOI: 10.5339/qmj.2020.48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/06/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Odai Khamash
- Hamad Medical Corporation, Anesthesia, ICU and Perioperative Medicine Department, P.O. Box. 3050, Doha, Qatar, E-mail:
| | | | | | | | | | - Abbas Moustafa
- Hamad Medical Corporation, Clinical Radiology and Medical Imaging Department, P.O. Box. 3050, Doha, Qatar
| | - Abhishek Menon
- Hamad Medical Corporation, ENT - ORL Department, P.O. Box. 3050, Doha, Qatar
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Lee S, Youn S, Chung W, Shin Y, Lim C. Extracorporeal membrane oxygenation for surgery to remove a huge goiter causing tracheal obstruction. Chirurgia (Bucur) 2020. [DOI: 10.23736/s0394-9508.19.05019-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Intubation of a Patient with a Large Goiter: The Advantageous Role of Videolaryngoscopy. Case Rep Anesthesiol 2019; 2019:1327482. [PMID: 31885930 PMCID: PMC6915117 DOI: 10.1155/2019/1327482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/15/2019] [Indexed: 11/17/2022] Open
Abstract
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.
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Perincek G, Avci S, Celtikci P. Retrosternal Goiter: A couple of classification methods with computed tomograpy findings. Pak J Med Sci 2018; 34:1494-1497. [PMID: 30559810 PMCID: PMC6290211 DOI: 10.12669/pjms.346.15932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Gokhan Perincek
- Dr. Gokhan Perincek, Department of Pulmonology, Kars Harakani State Hospital, Kars, Turkey
| | - Sema Avci
- Dr. Sema Avci, Department of Emergency Medicine, Sabuncuoglu Serefeddin Research and Training Hospital, Amasya, Turkey
| | - Pinar Celtikci
- Dr. Pinar Celtikci, Department of Radiology, Kars Harakani State Hospital, Kars, Turkey
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Kirk M, Ablaihed L, Dezman Z, Bontempo L. 65-year-old Female with Cardiac Arrest and Return of Spontaneous Circulation. Clin Pract Cases Emerg Med 2018; 2:181-186. [PMID: 30083628 PMCID: PMC6075500 DOI: 10.5811/cpcem.2018.6.38420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/23/2018] [Accepted: 06/14/2018] [Indexed: 11/11/2022] Open
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Baik FM, Zhu V, Patel A, Urken ML. Airway management for symptomatic benign thyroid goiters with retropharyngeal involvement: Need for a surgical airway with report of 2 cases. OTOLARYNGOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.xocr.2017.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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