Airways compromise after thyroidectomy - Forum

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Paranoid

Airways compromise after thyroidectomy - Ärzteforum

Post#1 »

In couple days, I'm going present a case on M&M. This is a 72 yo BF (325 lbs) with a h/o Lt thyroid lobectomy x3 apparently for a multinodular goiter in the outlying hospital presented with severe resp compromise. W/u (CAT scan) revealed Rt substernal goiter w/tracheal compression. NP scope revealed paralyzed Lt vocal cord. She was managed w/o preop intubation and did well. Bronchoscopy assisted intubation was easy although trachea was compressed down to about just 5 cm above the corina, so we had to advance the tip of the ET tube below the obstruction. Rt lobe thyroidectomy was uneventful, and we were able to scoop it out from behind the sternum without problems. Thyroid was easily peeled off the trachea and the trachea felt well, no evidence of tracheomalacia. Rt rec lar nerve was identified and preserved. We decided to keep her intubated overnight and extubate her in the am in the ICU. Five minute post extubation she developed severe stridor and desaturated down to 70%. Laryngoscopy revealed both vocal cords at midline and we failed to intubate her. Trach tray was at bedside and quick open trach was performed. We were flailing for about 5 minutes, and, thank God, patient's mental status was OK after she was well re-oxigenated. Patient has done well since then. We changed Portex trach to long Jackson and sent her home. Before she went home a NT scope was done which revealed minimal motions of the Rt vocal cord and severe laryngeal edema.

My question is:

What could we have done differently?
Extubate her in the OR?
Use bronchoscope, guidewire, or banana to stent cords before extubation?
May be she needed temporary trach anyway?
Has anybody had any experience with temporary lateral immobilization of cords?


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Billroth

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#2 »

Of course you recognized that you are managing a high risk airway (re-do thyroid operation with known pre-op L RN paralysis). You also promptly performed tracheostomy.

There are many details regarding this case that are pertinent. First, recurrent nerve injury (retraction, dissection, etc.) is easy to do. It is important during the case to treat the nerve with respect (both in the neck and mediastinum). Second, are you sure the nerve is out? You also described laryngeal edema. Leaving the endotracheal tube in overnight will probably increase laryngeal/glottic edema. So, I would not have left the tube in overnight. Extubation in the OR is ideal; you are set to do a trach if needed.

When you extubated the patient the next morning, there are some maneuvers you can do that may decrease the need for trach. (1) deflate the cuff (and occlude the lumen of the endotracheal tube) and see if the patient can ventilate "around the tube" while leaving the endotracheal tube in place; (2) nasopharyngoscopy can provide more info (larynx vs glottic problem); (3) extubate in the OR is always an option; (4) in the OR, you can sedate the patient and look at the cords (and of course do the trach, if necessary); (5) to minimize risk of bronchospasm, you can spray the cords with lidocaine; (6) if the problem is laryngeal edema, then there is a role for steroids, head elevation, and diuretics; and (7) from your description of the case, I would not have tried using difficult airway tools (stylet, bronchoscope, etc), but favor "rapid sequence," followed by trach.

I think the most important aspect of your case is that you recognized a difficult airway situation, were prepared to do a trach, then quickly recognized that a trach was indicated and consequently did it. However, by the "tone" of your presentation, you suggest that next time you will have EVERYTHING ready in the event that a trach is needed.

Scalpel

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#3 »

This patient had bilateral vocal cord paralysis. The emergency treatment is tracheostomy (however you may have saved yourself some anxiety by doing a cricothyroidotomy. Much faster, and just as effective).

The left recurrent laryngeal was damaged preoperatively, the question is how to avoid damage to the right one.

Roger S Foster has studied the PAS records of patients who had total thyroidectomies, he found that nation wide, 1% of patients required a tracheostomy, presumably for bilateral rec lar damage.

In this patient, there was no need to do a total Rt lobectomy. Avoiding a total lobectomy may have prevented the damage to the Rt recurrent nerve. The fact that the nerve was visualized and protected does not mean it was safe from damage. There are many surgeons, particularly on the east side of the Atlantic, who believe that if you see the nerve, the risk of damage is actually higher.

As this case was described, my preffered approach would be as described by Oliver Beahrs in his atlas, and that is to divide the isthmus first, place a series of streight clamps on the thyroid in parallel to the trachea, and divide the tyroid above the clamps. This will leave the thyroid tissue along the tracheo-esophageal groove intact. The inferior thyroid artery is transfixed and ligated laterally, close to its exit from the thyrocervical trunk, and away form the nerve.

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Surgeon

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#4 »

I would have trached the patient prophylactically at the end of the procedure. How can you assess tracheomalacia in an anesthetized patient who is not breathing spontaneously? The fact that she already had a RLN palsy on one side pre-op places her at high risk. Of course, hindsight is always 20/20.

Jorjo

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#5 »

Y Assume that you was tried of a old age patient with background of a tiroid surgery with diagnosis of left recurrent plus obesity and was practiced a surgery over a goiter that had grown toward the thorax of the right side which had produced furthermore a compression in midle third of the trachea. Given the risk of that as any patient even though you preserved the recurrent nerve they can have a temporary paresis or palsy (Fortunately is not very common, but can occur ) I would prefer in that case extubate wile in the . OR ( Y prefer ) or at ICU but under endoscopic control and , in the case of paresis y/o laringeal swelling would prolong the intubation starting corticoid therapy for about 24 to 48 hs. By other side the endoscopy durig extubation also serves for atraumatic and easy reintubation . If there is not section of the recurrent nerve the paresis may last 6 to 9 month up to finally to be recuperated . Thus that by now Y would not add most lesions to the larinx with another procedure . Y don't have experience with temporary lateral inmobilization of the cord but by have commented I do not believe that is indicated in this case that already has something of mobility and exist severe sweling . If there is not a tracheal malasis would not use a chanule very long given that in case of having some complication this would be most dangerous and difficult for resolving its .

John Dissector

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#6 »

Don't you risk compromising the parathyroid blood supply when you ligate the inferior thyroid artery laterally close to its origin? Or do you consider vascular compromise to the parathyroids a lesser evil than risking injurying the second recurrent laryngeal nerve in the case in question?

I do a classic Norm Thompson thyroidectomy (usually a total lobectomy, since the first time in is the safest, and I prefer to not risk having to go back for recurrent enlargement or lumps - that was actually one of the main problems with the case in question that the first surgeon did the left side 3 times), with a few recent modifications:

1. Mobilize the skin, subcutaneous tissue and platysma flaps down onto the clavicles and up above the thyroid notch;
2. Dissect the strap muscles completely from the manubrium to their insertions and laterally until the carotid artery and internal jugular veins are visualized
3. Retract the strap muscles cranially (may divide the sternothyroid from its thyroid cartilage attachment - if you do this, do it flush with the thyroid cartilage or it just gets in the way)
4. Place a clamp on the thyroid portion of the superior thyroid artery and retract laterocaudally
5. Open the cricothyroid space
6. Divide individual branches of the superior thyroid artery and vein

This reference suggests actually visualizing the superior laryngeal nerve - I am reluctant to do this, since I think as Avi does, that dissecting the nerve out to visualize it risks nerve injury.

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A Doctor

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#7 »

This is perhaps the most critical issue. Most problems with thyroid surgery that I have seen result from an incision too small, and flaps too narrow. Ditto for the straps.

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Schom

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#8 »

The most important thing to have done in this case was not to have injured/destroyed both recurrent laryngeal nerves, which is virtually the only reason for post-thyroidectomy stridor, and your laryngoscopic findings confirm this--she will need a permanent t5rach now until you can pex her cords, if that is ever possible.

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Old surgeon

Re: Airways compromise after thyroidectomy - Ärzteforum

Post#9 »

I have had one outstanding case of post thyroidectomy bilateral cord paralysis over the years. No excuses, but it really was a massive gland and a difficult op. Anyway I treated her with elective intubation with trials of extubation over several days until she rebelled, yanked the tube out and remained well thereafter .

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