Case of Stridor
Some advice on a case of stridor presenting in the ER today.
65 yr old male patient rural african background presents with severe stridor arising from a lower neck/superior mediastinal compressing lesion the would appear clinically to be a huge retrosternal thyroid. The trachea is in the centre of the mass and impalpable. The mass has been slowly growing for years, the stridor is recent – worse over a few days. He is otherwise well. We temporise with adrenaline nebulisation and I plan exploratory surgery on the morrow. Working diagnosis is either malignant change or haemorrhage into a preexisting goitre. I discuss the options with him and he emphatically declines any surgery. He then has a respiratory arrest and needed intubation. Now we are a bit stuck. Any suggestions!
Assuming this is a benign mass, he needs operative removal. Can a relative now give permission? It doesn’t sound like a malignancy so I don’t think there is any benefit from needle biopsy, etc.
No matter if benign or malign your patient has an emergency. You must tell him and his relatives that if he doesn’t accept the op, next step will be an emergency tracheostomy. If the circumstances allow, I think you must study the patient in order to reach a pathologic diagnosis, most probable you’ll find an anaplastic carcinoma, in which case the only one thing to do will be a definitively tracheostomy. If benign, you must do an excision of the mass, taking care of the trachea anatomy, which might be compromised as a tracheomalasya. Try to do a Bronchoscopy, it will give you a lot of info, about the trachea state, the situation of the cords and may be, tumoral compromise. Or easier, a neck US. Your patient is afraid of the op as many all over the world, try to get closer to him, make him feel your warmth, put his hand in yours, sometimes it helps, but above all you must to tell all your steps to the family, they also may help you.
Sound like he need sternotomy and tumor removal. Doubt, that extubation would be possible otherwise. Another problem is medico-legal – patient did want to have surgery done. This should be probably solved with relatives and medical council of your hospital. You may also check for undulating saw, that we use in cardiac surgery for redo cases.
There are a number of issues to unpack:
1. Bio-ethics. He declined operation when he was in sound mind, and his autonomy and habeas corpus must be respected. The only way around this is to communicate with him while he is intubated, and he may or may not have changed his mind. Only if he now freely and without coercion agrees to operation may you proceed.
2. This is probably a multinodular goitre [long history etc], which has undergone recent haemorrhage. I have always been able to remove these monsters through the conventional cervical incision, although have draped for median sternotomy, in case, but never done this. They usually break up a bit as you extract them.
3. He may have tracheomalacia, in addition to tracheal occlusion. This can be checked with a fibreoptic tracheoscope through the ET tube as it is withdrawn. Better would be to insert a transnasal ET tube at the end of the operation (a respirator is not really necessary), and leave it for a couple of days.
Do give us a follow up.
On discussion with other colleagues (relatives were as is often the case for us unavailable) we elected to operate – to resect the obstructing tumour if possible, and to establish a tracheostomy if not. Despite the history and initial clinical impression he had a rubbery tumour extensively involving the peritracheal tissues (but not invading into the tracheal mucosa) extending down into the superior mediastinum and denslely adherent to vital structures. I suppose this must be an anaplastic tumour arising from a preexistent multinodular goitre though I could find no obvious residual multinodular thyroid tissue to confirm this. the bleeding was most troublesome due to a superior mediastinal syndrome, and we elected to do a median sternotomy for better access to the mass before giving up entirely on resectional surgery. We were able to establish a tracheostomy and the patient is at present on ICU – hopefully will recover enough to leave hospital but at present the immediate outcome is in doubt. Not a good experience for any of us but difficult to know how we could have done better. (Pathology of any sort is 200K away and with the best efforts takes at least a week) I will post the pathology when available and further progress.
Your differential is haemorrhage into the multinodular goiter vs. malignancy. If this is a malignancy (which seems to be unlikely) that will be anaplastic CA or lymphoma. Thyroidectomy is not an option in both cases. As for benign disease, this is a true emergency now. I would start this case with the neck incision and wedge out the part of the thyroid which is overlying the anterior tracheal wall and send it for frozen. If it is a malignancy, I would place the trach and send the patient to oncologist. If no malignancy is found, I would proceed with thyroidectomy through the collar incision: it is feasible in majority of cases and sternotomy may be avoided.
Bio-etical problem seems to be rather complicated now. In some countries, in case of emergency, a commission of three physicians can decide on patient’s behalf. Otherwise reasonable family members (next to kin) should be approached and convinced in necessity of the procedure. Everything must be well documented on the chart. Your actions must be obviously dependent on your country’s laws and regulations.