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Soewoto W, Ardianti M. Tracheomalacia following a total thyroidectomy in a patient with a large non-toxic goiter: A case report. Int J Surg Case Rep 2024; 116:109211. [PMID: 38310789 PMCID: PMC10847800 DOI: 10.1016/j.ijscr.2023.109211] [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: 11/22/2023] [Revised: 12/23/2023] [Accepted: 12/27/2023] [Indexed: 02/06/2024] Open
Abstract
INTRODUCTION Nontoxic nodular goiter is one of the most prevalent thyroid conditions worldwide. Thyroidectomy for large goiters has a relatively high risk of postoperative airway obstruction, with tracheomalacia being one of the potential complications. CASE REPORT A 61-year-old woman complained of a lump in her neck for 45 years. The node is progressively enlarged, but she did not experience any breathing difficulty, hoarseness, or pain while swallowing. A total thyroidectomy was then performed. The histopathologic examination revealed colloid goiter. During the procedure, evaluation of the trachea revealed a tracheomalacia, so a tracheotomy was then performed on the patient. After a follow-up period of three months, the patient was no longer experiencing tracheomalacia, and the tracheostomy was successfully closed. DISCUSSION Surgery has been considered an acceptable approach for managing non-toxic goiter. The most common indications are compressive symptoms, substernal extension, inability to control hyperthyroidism through medication, and a suspicion of malignancy. However, thyroidectomy for large goiter carries a relatively high risk of postoperative respiratory obstruction. Diagnosing tracheomalacia can be challenging and often relies on bronchoscopy to assess the airway and observe the collapse of cartilage and membranes. Acquired tracheomalacia can be managed through internal or external stenting or tracheostomy. CONCLUSION Total thyroidectomy has been recommended as a suitable procedure for non-toxic and toxic multinodular goiter. Tracheomalacia may occur following thyroidectomy in patients with thyroid enlargement. Tracheostomy effectively manages tracheomalacia by creating a channel across the malacia's focal segment, restoring the airway's patency.
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Affiliation(s)
- Widyanti Soewoto
- Surgical Oncology Department, Medical Faculty of Universitas Sebelas Maret, Dr. Moewardi Hospital, Surakarta, Indonesia.
| | - Meirisa Ardianti
- Surgery Department, Medical Faculty of Universitas Sebelas Maret, Dr. Moewardi Hospital, Surakarta, Indonesia
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Andrew O, Folorunsho O, Faustina B, Alufohai EJ, Andrew D. A case report of tracheal tenting to the skin: An option to tracheostomy for post-thyroidectomy tracheomalacia. Niger J Clin Pract 2023; 26:1579-1583. [PMID: 37929539 DOI: 10.4103/njcp.njcp_472_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Operating on a huge and long-standing goiter is challenging to the surgeon and anesthetist because of the possibility of tracheomalacia and collapse of the tracheal rings after extubation. We report our innovation of tenting the trachea to the skin using sutures (passed through the strap and sternocleidomastoid muscles) to prevent post-thyroidectomy tracheomalacia.
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Affiliation(s)
- O Andrew
- Department of Surgery, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - O Folorunsho
- Department of Anaesthesia, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - B Faustina
- Department of ENT, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
| | - E J Alufohai
- Joe Alufohai Medical Centre, Sabongida-Ora, Edo State, Nigeria
| | - D Andrew
- Department of Surgery, Ambrose Alli University, Ekpoma, Edo State, Nigeria
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Campennì A, Avram AM, Verburg FA, Iakovou I, Hänscheid H, de Keizer B, Petranović Ovčariček P, Giovanella L. The EANM guideline on radioiodine therapy of benign thyroid disease. Eur J Nucl Med Mol Imaging 2023; 50:3324-3348. [PMID: 37395802 PMCID: PMC10542302 DOI: 10.1007/s00259-023-06274-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023]
Abstract
This document provides the new EANM guideline on radioiodine therapy of benign thyroid disease. Its aim is to guide nuclear medicine physicians, endocrinologists, and practitioners in the selection of patients for radioiodine therapy. Its recommendations on patients' preparation, empiric and dosimetric therapeutic approaches, applied radioiodine activity, radiation protection requirements, and patients follow-up after administration of radioiodine therapy are extensively discussed.
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Affiliation(s)
- Alfredo Campennì
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Unit of Nuclear Medicine, University of Messina, Messina, Italy
| | - Anca M Avram
- Departments of Radiology and Medicine, MetroHealth Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Frederik A Verburg
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - Ioannis Iakovou
- Academic Department of Nuclear Medicine, University Hospital AHEPA, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Academic Department of Nuclear Medicine, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Heribert Hänscheid
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Petra Petranović Ovčariček
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Luca Giovanella
- Clinic for Nuclear Medicine, Ente Ospedaliero Cantonale, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Clinic for Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
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Abstract
Retro-sternal goitres are slow growing in nature. Dyspnoea on exertion is the most common presenting symptom due to the pressure effect of goitre on trachea. Due to the increased use of radiological investigations, retrosternal goitres are often diagnosed incidentally without any symptoms. Surgical resection is considered the gold standard management in all symptomatic patients and most of asymptomatic patients. However, "wait and watch" approach is an option, in selected asymptomatic patients, with the evolution of alternative treatment methods. So, the management of retrosternal goitre continues to be a surgical controversy. This article aims at reviewing the evidence-based practice of management of retrosternal goitres including challenges of surgery and postoperative complications.
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Sulaiman A, Lutfi A, Ikram M, Fatimi S, Bin Pervez M, Shamim F, Abbas SA, Iftikhar H. Tracheomalacia after thyroidectomy for retrosternal goitres requiring sternotomy- a myth or reality? Ann R Coll Surg Engl 2021; 103:504-507. [PMID: 34192497 DOI: 10.1308/rcsann.2021.0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Tracheomalacia after thyroidectomy is not well understood. Reports on tracheomalacia are conflicting, with some suggesting a high rate and other large cohorts in which no tracheomalacia is reported. The aim of our study was to assess the incidence and factors associated with tracheomalacia after thyroidectomy in patients with retrosternal goitres requiring sternotomy at a high-volume tertiary care referral centre. METHODS A longitudinal cohort study was conducted from January 2011 to December 2019. All adult patients who underwent thyroidectomy with sternotomy were included. Tracheomalacia was considered when tracheal rings were soft compared with other parts (proximal or distal) of the trachea and required either tracheostomy or resection with anastomosis. The decision to perform a tracheostomy or to administer continuous or bilevel positive airway pressure postoperatively was made depending on the degree of tracheomalacia. Logistic regression analysis was used to assess factors associated with tracheomalacia. RESULTS We evaluated 40 patients who underwent thyroidectomy with sternotomy. The mean age of our cohort was 48.7 ± 11.3 years and the population was predominantly female (67.5%). One patient required tracheal resection with anastomosis, and two patients required tracheostomy. Multivariable logistic regression analysis did not reveal any patient- or thyroid-related factor significantly associated with the development of tracheomalacia in our cohort. CONCLUSIONS The incidence of tracheomalacia after thyroidectomy with sternotomy appears to be very low. However, the occurrence of tracheomalacia after thyroidectomy in cases of large goitre is possible and hence worrisome.
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Affiliation(s)
- A Sulaiman
- Aga Khan University Hospital, Karachi, Pakistan
| | - A Lutfi
- Aga Khan University Hospital, Karachi, Pakistan
| | - M Ikram
- Aga Khan University Hospital, Karachi, Pakistan
| | - S Fatimi
- Aga Khan University Hospital, Karachi, Pakistan
| | | | - F Shamim
- Aga Khan University Hospital, Karachi, Pakistan
| | - S A Abbas
- Aga Khan University Hospital, Karachi, Pakistan
| | - H Iftikhar
- Aga Khan University Hospital, Karachi, Pakistan
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Pan Y, Chen C, Yu L, Zhu S, Zheng Y. Airway Management of Retrosternal Goiters in 22 Cases in a Tertiary Referral Center. Ther Clin Risk Manag 2020; 16:1267-1273. [PMID: 33376336 PMCID: PMC7764631 DOI: 10.2147/tcrm.s281709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/03/2020] [Indexed: 11/23/2022] Open
Abstract
Background The present study aimed to investigate the incidence and extent of difficult airway management in patients with massive retrosternal goiter. Design An 8-year retrospective analysis was performed to identify patients who underwent massive retrosternal thyroidectomy. A total of 22 cases were identified as giant retrosternal goiter, followed by a review of each patient’s preoperative computerized tomography imaging. Interventions There were no cases of failed intubation. Twenty patients underwent uneventful tracheal intubation using direct laryngoscopy or Glidescope. Thirteen patients received a muscle relaxant intravenously, and two patients were induced with sevoflurane. Five patients underwent awake tracheal intubation, including awake fiberoptic intubation in three patients. Before entering the operating theatre, the remaining two patients underwent oral tracheal intubation with Glidescope in the emergency department. Results Two patients had tracheal intubation before they entered the operating theatre. Once entering vocal cords, tracheal intubation can pass beyond the site of the tracheal obstruction without difficulty. One patient died because of serious perioperative bleeding owing to the adhesion between the retrosternal goiter and large vessel within the thoracic cavity. One patient experienced dyspnea after extubation and was intubated again. Conclusion Intravenous induction of muscle relaxant using laryngoscopy or Glidescope is feasible in patients with massive benign retrosternal goiter. The incidence of difficult intubation and postoperative tracheomalacia is likely too rare. Furthermore, perioperative bleeding and postoperative airway complication seem frequent.
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Affiliation(s)
- Yuanming Pan
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, People's Republic of China
| | - Chaoqin Chen
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, People's Republic of China
| | - Lingya Yu
- Department of Radiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, People's Republic of China
| | - Shengmei Zhu
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, People's Republic of China
| | - Yueying Zheng
- Department of Anesthesiology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, People's Republic of China
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Chughtai AR, Agarwal PP. Tracheobronchomalacia in the Adult: Is Imaging Helpful? CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-00228-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Good JT, Rollins DR, Kolakowski CA, Stevens AD, Denson JL, Martin RJ. New insights in the diagnosis of chronic refractory cough. Respir Med 2018; 141:103-110. [PMID: 30053955 DOI: 10.1016/j.rmed.2018.06.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/22/2018] [Accepted: 06/26/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic Refractory Cough (CRC) is a common condition that significantly impairs patients' quality of life. Unfortunately, in many situations patients continue to experience CRC in spite of following published guidelines for diagnosis and treatment. METHODS 99 patients were referred to National Jewish Health (NJH), a specialty respiratory center for evaluation of CRC (cough ≥ 8 weeks duration). Study duration occurred over 18 months. Intake evaluation for all patients included history, physical examination, spirometry and fiberoptic laryngoscopy. Testing to confirm causes of CRC were performed. Specific therapy for each potential cause was provided. A visual analog cough scale measured cough response. RESULTS Ten final diagnostic categories were found in the cohort of 99 patients with CRC: Obstructive sleep apnea (apnea/hypoxia index ≥ 5), rhinosinusitis, Tracheobronchomalacia (≥65% collapse of airway with dynamic expiratory imaging), esophageal dysmotility, gastroesophageal reflux, abnormal swallowing with laryngeal penetration, asthma, COPD, bronchiectasis and paradoxical vocal cord movement. In these patients there were 42 incorrect intake diagnoses and 101 new diagnoses established. Patients with CRC have had multiple diagnoses (3.8 ± 1.6) associated with chronic cough. With directed therapy 71/76 (93%) patients had resolution or improvement in cough symptoms. CONCLUSIONS Among patients referred to a specialty respiratory center with CRC multiple concomitant diagnoses for cough were common. Certain diagnoses such as OSA and TBM have not been reported in cough guidelines but in this study are commonly associated diagnoses. Targeted therapy for each recognized diagnosis improves patient response.
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Affiliation(s)
- James T Good
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO, 80206, USA.
| | - Donald R Rollins
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO, 80206, USA.
| | - Christena A Kolakowski
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO, 80206, USA.
| | - Allen D Stevens
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO, 80206, USA.
| | - Joshua L Denson
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO, 80206, USA.
| | - Richard J Martin
- Department of Medicine, National Jewish Health, 1400 Jackson St, Denver, CO, 80206, USA.
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Gomez-Larrauri A, Galloway S, Niven R. Achalasia with massive oesophageal dilation causing tracheomalacia and asthma symptoms. Respir Med Case Rep 2017; 23:80-82. [PMID: 29321968 PMCID: PMC5752331 DOI: 10.1016/j.rmcr.2017.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/12/2017] [Accepted: 12/14/2017] [Indexed: 12/04/2022] Open
Abstract
Achalasia is an uncommon oesophageal motor disorder characterized by failure of relaxation of the lower oesophageal sphincter and muscle hypertrophy, resulting in a loss of peristalsis and a dilated oesophagus. Gastrointestinal symptoms are invariably present in all cases of achalasia observed in adults. We report a case of a 34 year-old female patient with long standing history of asthma-like symptoms, labelled as uncontrolled and steroid resistant asthma with no gastrointestinal manifestations. Thoracic CT scan revealed a massive oesophagus due to achalasia, which caused severe tracheomalacia as a result of tracheal compression. Her symptoms regressed completely after a laparoscopic Heller myotomy surgery intervention.
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Affiliation(s)
- Ana Gomez-Larrauri
- MAHSC, The University of Manchester and University Hospital of South Manchester, Southmoor Road, M23 9LT, Manchester, UK.,Respiratory Department, University Hospital of Araba, Jose Atxotegi, s/n, 01009, Vitoria-Gasteiz, Araba, Spain
| | - Simon Galloway
- MAHSC, The University of Manchester and University Hospital of South Manchester, Southmoor Road, M23 9LT, Manchester, UK
| | - Rob Niven
- MAHSC, The University of Manchester and University Hospital of South Manchester, Southmoor Road, M23 9LT, Manchester, UK
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Abstract
The term tracheobronchomalacia refers to excessively compliant and collapsible central airways leading to symptoms. Although seen as a coexisting condition with various other pulmonary condition, it may cause symptoms by itself. The condition is often misdiagnosed as asthma, bronchitis or just chronic cough due to a lack of specific pathognomonic history and clinical findings. The investigation revolves around different modes of imaging, lung function testing and usually confirmed by flexible bronchoscopy. The treatment widely varies based on the cause, with most cases treated conservatively with non-invasive ventilation. Some may require surgery or stent placement. In this article, we aim to discuss the pathophysiology behind this condition and recognize the common symptoms and causes of tracheobronchomalacia. The article will highlight the diagnostic steps as well as therapeutic interventions based on the specific cause.
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Affiliation(s)
- Abhishek Biswas
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States.
| | - Michael A Jantz
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - P S Sriram
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
| | - Hiren J Mehta
- Division of Pulmonary and Critical Care Medicine, University of Florida, Gainesville, FL, United States
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Padmanabhan A, Thomas AV, Sandeep GSK. Aberrant right subclavian artery syndrome manifesting as focal tracheomalacia. Lung India 2017; 34:292-294. [PMID: 28474661 PMCID: PMC5427763 DOI: 10.4103/0970-2113.205328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Tracheomalacia is one of the rarest etiologies of chronic cough. Herein, we present the case of an elderly woman with chronic cough who on detailed evaluation was found to have focal (localized) tracheomalacia due to compression by an aberrant right subclavian artery (arteria lusoria). The absence of dysphagia in this patient also deserves particular mention.
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Affiliation(s)
- Arjun Padmanabhan
- Department of Respiratory Medicine, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - Abin Varghese Thomas
- Department of Respiratory Medicine, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | - G S K Sandeep
- Department of Radiodiagnosis, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
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Tsilimigras DI, Patrini D, Antonopoulou A, Velissaris D, Koletsis E, Lawrence D, Panagiotopoulos N. Retrosternal goitre: the role of the thoracic surgeon. J Thorac Dis 2017; 9:860-863. [PMID: 28449497 DOI: 10.21037/jtd.2017.02.56] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Purpose of this Mini-Review is to evaluate the role of a thoracic surgeon in the surgical management of retrosternal goitre. A cervical approach is sufficient in the majority of the cases. On the other hand, there are cases where a cervical approach is combined with sternotomy or thoracotomy, depending on the position of the goitre, in the anterior or posterior mediastinum. On top of that, different minimally invasive approaches including video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery (RATS) have been introduced, providing faster recovery, superior manoeuvrability and better aesthetic results.
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Affiliation(s)
- Diamantis I Tsilimigras
- Department of Cardiothoracic Surgery, University College London Hospitals (UCLH), London, UK
| | - Davide Patrini
- Department of Cardiothoracic Surgery, University College London Hospitals (UCLH), London, UK
| | - Aspasia Antonopoulou
- Department of Cardiothoracic Surgery, University College London Hospitals (UCLH), London, UK
| | | | | | - David Lawrence
- Department of Cardiothoracic Surgery, University College London Hospitals (UCLH), London, UK
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Azuma K, Oda J, Oda K, Homma H, Azuma H, Uchida K, Matsuoka Y, Kobayashi T, Yukioka T. A 71-year-old female with giant goiter associated with tracheomalacia. Acute Med Surg 2014; 1:242-244. [PMID: 29930856 DOI: 10.1002/ams2.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 04/15/2014] [Indexed: 11/11/2022] Open
Abstract
Case A 71-year-old woman was admitted to the Emergency Department with severe dyspnea followed by unconsciousness. She had a history of hyperthyroidism and her anterior neck was markedly swollen. After ventilation was started, she soon became conscious with the improvement of oxygenation. Computed tomography findings indicated giant goiter surrounding the trachea. Later, we carried out a thyroidectomy for the giant goiter (800 g), and tracheostomy. Bronchoscopy carried out at the end of surgery showed a deformed tracheal wall on breathing. During inspiration, the collapsed wall of the trachea occluded the airway, although the tracheal wall recovered to normal during expiration. We diagnosed this case as acquired tracheomalacia and a tracheal stent graft made of silicon was inserted immediately after bronchoscopy. Outcome After stent graft insertion, the patient was transferred to another hospital. Conclusion Emergency physicians should be aware of the causes of tracheomalacia in order to safely carry out treatment, particularly in the case of patients with giant goiter.
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Affiliation(s)
- Kazunari Azuma
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Jun Oda
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Kaori Oda
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Hiroshi Homma
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Hikohiro Azuma
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Kotaro Uchida
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Yuji Matsuoka
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Tomoko Kobayashi
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
| | - Tetsuo Yukioka
- Department of Emergency and Critical Care Medicine Tokyo Medical University Tokyo Japan
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Phelan E, Schneider R, Lorenz K, Dralle H, Kamani D, Potenza A, Sritharan N, Shin J, W. Randolph G. Continuous vagal IONM prevents recurrent laryngeal nerve paralysis by revealing initial EMG changes of impending neuropraxic injury: A prospective, multicenter study. Laryngoscope 2014; 124:1498-505. [DOI: 10.1002/lary.24550] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Eimear Phelan
- Division of Thyroid and Parathyroid Surgery; Department of Laryngology and Otology; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts
| | - Rick Schneider
- Division General-Visceral and Vascular Surgery; University of Halle-Wittenberg; Halle Germany
| | - Kerstin Lorenz
- Division of Surgical Oncology; Department of Surgery; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
| | - Henning Dralle
- Division General-Visceral and Vascular Surgery; University of Halle-Wittenberg; Halle Germany
| | - Dipti Kamani
- Division of Thyroid and Parathyroid Surgery; Department of Laryngology and Otology; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts
| | - Andre Potenza
- Division of Thyroid and Parathyroid Surgery; Department of Laryngology and Otology; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts
| | - Niranjan Sritharan
- Division of Thyroid and Parathyroid Surgery; Department of Laryngology and Otology; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts
| | - Jenifer Shin
- Division of Thyroid and Parathyroid Surgery; Department of Laryngology and Otology; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts
| | - Gregory W. Randolph
- Division of Thyroid and Parathyroid Surgery; Department of Laryngology and Otology; Massachusetts Eye and Ear Infirmary; Harvard Medical School; Boston Massachusetts
- Division of Surgical Oncology; Department of Surgery; Massachusetts General Hospital; Harvard Medical School; Boston Massachusetts
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15
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Dempsey GA, Snell JA, Coathup R, Jones TM. Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. Br J Anaesth 2013; 111:594-9. [PMID: 23690528 DOI: 10.1093/bja/aet151] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Retrosternal goitre (RSG) is an uncommon problem encountered rarely by anaesthetists working outside specialized head and neck (H&N) surgical units. Traditional anaesthetic teaching warns of difficult airway management in these patients. The incidence and extent of these problems is unclear. METHODS We have performed a retrospective review of the anaesthetic management all patients with massive RSG (extending to the aortic arch or beyond) presenting for thyroidectomy at University Hospital Aintree from January 2007 to May 2012. RESULTS Five hundred and seventy-three patients underwent a thyroidectomy procedure at Aintree University Hospitals NHS Foundation Trust (AUH) between January 2007 and May 2012. Of these, 34 cases were documented as having a RSG. Review of each patient's preoperative computerized tomography imaging identified 19 patients with massive RSG. There was one case of failed intubation. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed through the neck with no requirement to proceed to sternotomy. There were no instances of postoperative respiratory problems or tracheomalacia. Three patients suffered recurrent laryngeal nerve (RLN) injuries. CONCLUSION When managed within a dedicated H&N operating theatre we have found a low incidence of difficult tracheal intubation, difficult mechanical ventilation nor postoperative respiratory difficulties in patients with massive RSG and mid-tracheal compression because of benign multi-nodular goitre. Surgical complications, however, are more frequent than those associated with cervical thyroidectomy with RLN injury and postoperative bleeding more likely.
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Affiliation(s)
- G A Dempsey
- Department of Anaesthesia and Critical Care and
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16
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Sabaretnam M, Mishra A. Re: Noninvasive positive pressure ventilation in the management of post-thyroidectomy tracheomalacia. World J Surg 2012; 36:1207. [PMID: 22131092 DOI: 10.1007/s00268-011-1369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mayilvaganan Sabaretnam
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Anjali Mishra
- Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India.
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17
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Abstract
The main causes of simple diffuse goiter (SDG) and multinodular goiter (MNG) are iodine deficiency, increase in serum thyroid-stimulating hormone (TSH) level, natural goitrogens, smoking, chronic malnutrition, and lack of selenium, iron, and zinc. Increasing evidence suggests that heredity is equally important. Treatment of SDG and MNG still focuses on L-thyroxine-suppressive therapy surgery. Radioiodine alone or preceded by recombinant human TSH stimulation is widely used in Europe and other countries. Each of these therapeutic options has advantages and disadvantages, with acute and long-term side effects.
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Affiliation(s)
- Geraldo Medeiros-Neto
- Division of Endocrinology, Department of Medicine, University of Sao Paulo Medical School, Rua Artur Ramos, 96 - 5A, 01454-903 Sao Paulo, Brazil.
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Management of a patient with tracheomalacia and supraglottic obstruction after thyroid surgery. Can J Anaesth 2011; 58:1029-33. [DOI: 10.1007/s12630-011-9570-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 07/27/2011] [Indexed: 10/17/2022] Open
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Chi SY, Wu SC, Hsieh KC, Sheen-Chen SM, Chou FF. Noninvasive Positive Pressure Ventilation in the Management of Post-thyroidectomy Tracheomalacia. World J Surg 2011; 35:1977-83. [DOI: 10.1007/s00268-011-1178-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Tracheomalacia after reoperation for an adenomatous goiter located in a unique position. J Anesth 2011; 25:745-8. [DOI: 10.1007/s00540-011-1181-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 05/23/2011] [Indexed: 11/25/2022]
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21
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Pradeep PV, Sattar V, Krishnachaithanya K, Ragavan M. Huge thyromegaly: challenges in the management. ANZ J Surg 2011; 81:398-400. [PMID: 21518207 DOI: 10.1111/j.1445-2197.2011.05721.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Findlay JM, Sadler GP, Bridge H, Mihai R. Post-thyroidectomy tracheomalacia: minimal risk despite significant tracheal compression. Br J Anaesth 2011; 106:903-6. [PMID: 21450708 DOI: 10.1093/bja/aer062] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Tracheomalacia is a feared complication of goitre surgery, but considered rare in the Western World. This study aimed to estimate the risk of tracheomalacia in a contemporary series of patients with goitres causing significant tracheal compression. METHODS A retrospective review was conducted of thyroidectomies performed in a UK tertiary referral centre over a 30 month period. Anaesthetic, operative, radiological, and pathological data were obtained from medical notes and hospital software systems. RESULTS Of 334 patients who underwent thyroid surgery, preoperative CT scan was performed in 101 (30%). Tracheal compression was reported in 62 patients (19%) with minimum tracheal diameter ranging from 2 to 15 mm (mean 7.6 mm) due to multinodular goitre (n=50), malignancy (n=10), or thyroiditis (n=2). Critical compression <5 mm was observed in 18 patients (6%) and 35 patients had compression to 6-10 mm. Awake fibreoptic intubation was performed in eight patients (six of those with tracheas <5 mm) and asleep fibreoptic intubation was performed in one. Standard intubation was performed otherwise. All patients were recovered on a general surgical ward. None required tracheostomy or tracheal stenting. The incidence of tracheomalacia was 0 (95% confidence interval 0.0-4.8%). Mean length of stay was 2.4 days in those with tracheas <5 mm and 2.0 days in those >5 mm. CONCLUSIONS We found no evidence of tracheomalacia in high-risk patients with significant tracheal compression. This supports prior work on retrosternal goitres suggesting that the risk of tracheomalacia is minimal in modern thyroid surgery. For risk management, however, we would still advocate that such patients be managed in units with multispeciality support.
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Affiliation(s)
- J M Findlay
- Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU, UK
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23
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Bonnema SJ, Nielsen VE, Hegedüs L. Radioiodine therapy in non-toxic multinodular goitre. The possibility of effect-amplification with recombinant human TSH (rhTSH). Acta Oncol 2009; 45:1051-8. [PMID: 17118838 DOI: 10.1080/02841860600617084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
There is no consensus regarding the optimum treatment of benign non-toxic goitre. L-thyroxine suppressive therapy is widely used, but there is poor evidence of its efficacy, and it may have serious adverse effects on health. Surgery is first choice in large goitres or if malignancy is suspected. 131I therapy results in a one-year goitre reduction of around 40% in multinodular goitres, usually with a high degree of patient satisfaction and improvement of the inspiratory capacity. The effect is attenuated with increasing goitre size. The risk of hypothyroidism is 22-58% within 5-8 years. A sufficient thyroid 131I uptake is mandatory for 131I therapy to be feasible and pre-stimulation with recombinant human TSH (rhTSH) increases this considerably. This leads to an increased absorbed thyroid dose by approx.75%, mainly in those patients with the lowest thyroid 131I uptake, and a more homogeneous intrathyroidal isotope distribution. Pre-stimulation with even a small dose of rhTSH seems to allow a reduction of the 131I activity while still achieving a mean goitre reduction of approximately 40% within a year. A significantly lower extrathyroidal radiation is achieved by this approach. With an unchanged 131I activity, rhTSH pre-stimulation improves the goitre reduction by 30-50%. However, this is at the expense of a higher rate of hypothyroidism, cervical pain and transient thyrotoxicosis. Of particular concern is the observation made in healthy persons, that rhTSH results in a transient average thyroid volume increase of 35%. A similar goitre swelling may cause problems in susceptible patients during rhTSH-augmented 131I therapy. Thus, this concept still needs a closer evaluation before routine use.
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Affiliation(s)
- Steen J Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Denmark.
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Rahman GA. Possible Risk Factors for respiratory Complications after Thyroidectomy: An Observational Study. EAR, NOSE & THROAT JOURNAL 2009. [DOI: 10.1177/014556130908800415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
It is widely accepted that thyroid surgery is not without morbidity. One well known postoperative complication is respiratory distress. The aim of this prospective observational study was to determine the incidence of post-thyroidectomy respiratory complications and to identify possible predictive factors. The study population was made up of 262 patients who had undergone thyroidectomy for goiter at the University of Ilorin Teaching Hospital in Nigeria from January 1989 through December 2003. Information was collected on 8 possible predictive factors for respiratory complications: (1) the duration of the goiter, (2) the preoperative status of the recurrent laryngeal nerve, (3) the presence or absence of tracheal narrowing or deviation, (4) the presence or absence of retrosternal extension, (5) the ease or difficulty of endotracheal intubation, (6) the presence or absence of thyroid cancer, (7) the presence or absence of giant goiter, and (8) whether or not the goiter represented a recurrence. Respiratory complications occurred in 20 of the 262 patients (7.6%). Of these 20 patients, 16 (80%) had a goiter of at least 5 years’ duration, 12 (60%)) had a giant goiter, 5 (25%) had tracheal narrowing, 4 (20%) had a malignant goiter, 3 (15%) had palsy of the recurrent laryngeal nerve preoperatively, and 2 patients each (10%) had retrosternal extension, a difficult intubation, or a recurrent goiter. Twelve patients (60%) had at least 4 of the 8 possible risk factors, and 6 others (30%) had 3 factors. Postoperative tracheotomy was necessary for 4 patients. No deaths occurred. While the findings of this observational study can only suggest the possibility of causation, preoperative factors such as long-standing goiter and giant goiter should be taken into consideration in postoperative management and the prevention of respiratory complications. In addition, the presence of at least 4 of the 8 factors studied should likewise alert the management team.
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Affiliation(s)
- Ganiyu A. Rahman
- Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
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25
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White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg 2008; 32:1285-300. [PMID: 18266028 DOI: 10.1007/s00268-008-9466-3] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology. METHODS This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution. RESULTS Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nerve injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation). CONCLUSION Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.
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Affiliation(s)
- Matthew L White
- Division of Endocrine Surgery, Department of Surgery, University of Michigan, 2920 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0331, USA
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Iglesias Bolaños P, Pavón de Paz I, Díaz Guardiola P, Guijarro de Armas G, Javier Penín González F, Peña RE. Radioiodine therapy for multinodular goiter. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2008; 55:263-266. [PMID: 22964127 DOI: 10.1016/s1575-0922(08)70681-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Accepted: 03/17/2008] [Indexed: 06/01/2023]
Abstract
Treatment options for large, compressive goiters are currently limited to surgery and radioiodine administration. Classically, the first-line option has been surgery, with radioiodine therapy being reserved as an alternative treatment in patients with high surgical risk. We describe the case of an 81-year-old woman with a large, compressive multinodular goiter and hyperthyroidism, substernal extension and associated co-morbidity, contraindicating surgery. We review the efficacy of different treatment options for compressive multinodular goiter, as well as the potential secondary complications.
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Affiliation(s)
- Paloma Iglesias Bolaños
- Servicio de Endocrinología y Nutrición. Hospital Universitario de Getafe. Getafe. Madrid. España
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27
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Tracheostomy with thyroidectomy: indications, management and outcome: a prospective study. Int J Surg 2008; 6:147-50. [PMID: 18343210 DOI: 10.1016/j.ijsu.2008.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Accepted: 01/30/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study aims to determine the indications, course and outcome of pre-operative and post-thyroidectomy tracheostomy. SUBJECTS AND METHODS This is a prospective descriptive study conducted in Khartoum Teaching Hospital in the period between March 2000 and March 2005. Fifty-nine patients had tracheostomy out of 964 thyroidectomy patients, giving an incidence of 6%. RESULTS The decision of doing tracheostomy was taken intra-operatively in 41 patients (69%), all presenting with strider. In 25 of those 41 patients there was intra-operative tracheal deformity with narrowing (>50% of tracheal circumference on radiology) and gland adherence to the tracheal wall; the remaining 16 patients had tracheomalacia. Of those 41 patients, 25 presented with severe strider and needed urgent surgery (5 with recurrent anaplastic carcinoma, 5 with intrathoracic goitres that necessitated median sternotomy and 15 with huge goitres (of whom 7 were recurrent goitres). In the remaining 18 patients (31%) emergency post-operative tracheostomy was done following endotracheal extubation up to 48 h post-operatively. There were 2 deaths (3.4%); one patient died due to tracheostomy care and the other from myocardial infarction. CONCLUSION Tracheostomy is a safe procedure and gives a good alternative to delayed endotracheal extubation in post-thyroidectomy patients expected to have respiratory failure in places where post-operative anaesthetic care is lacking.
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Capdeville M. The Management of a Patient With Tracheal Compression Undergoing Combined Resection of an Anterior Mediastinal Mass and Aortic Valve Replacement With Coronary Artery Bypass Graft Surgery: Utility of the Laryngeal Mask Airway and Aintree Intubation Catheter. J Cardiothorac Vasc Anesth 2007; 21:259-61. [PMID: 17418744 DOI: 10.1053/j.jvca.2006.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Michelle Capdeville
- Department of Anesthesiology, University Hospitals of Cleveland/Case Western Reserve University School of Medicine, Cleveland, OH 44106-5007, USA.
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29
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Abstract
Tracheobronchomalacia and excessive dynamic airway collapse are two separate forms of dynamic central airway obstruction that may or may not coexist. These entities are increasingly recognized as asthma and COPD imitators. The understanding of these disease processes, however, has been compromised over the years because of uncertainties regarding their definitions, pathogenesis and aetiology. To date, there is no standardized classification, diagnosis or management algorithm. In this article we comprehensively review the aetiology, morphopathology, physiology, diagnosis and treatment of these entities.
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Affiliation(s)
- Septimiu D Murgu
- Pulmonary and Critical Care Medicine, Department of Medicine, University of California School of Medicine, Irvine, CA, USA
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30
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Ahmed ME, Ahmed EO, Mahadi SI. Retrosternal Goiter: The Need for Median Sternotomy. World J Surg 2006; 30:1945-8; discussion 1949. [PMID: 16902739 DOI: 10.1007/s00268-006-0011-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The aim of this study was to analyze the features of patients with goiter who underwent thyroidectomy via a cervical incision and a median sternotomy in Khartoum. METHODS A total of 267 thyroidectomies were performed in Khartoum Teaching Hospital during the period from January 2002 to December 2003. There were 40 patients with evidence of retrosternal goiter (15%). Of those 40 patients, 13 had clinical and radiologic evidence of deep retrosternal extension of the goiter possibly necessitating sternotomy. Only 9 of the 13 patients actually required sternotomy, which accounted for 3.4% of all thyroidectomies performed (n = 267). The clinical, radiologic, and pathologic findings of those 9 sternotomy patients were analyzed and compared to those of the 258 patients who underwent cervical thyroidecomy. RESULTS Total thyroidectomy was undertaken in all nine patients. Six of them had retrosternal extension on the right side of the mediastinum, and three had bilateral extension. Seven patients had symptoms of respiratory distress, and two were asymptomatic. The duration of the goiter ranged between 7 and 30 years. The chest radiograph and computed tomography scan revealed that the retrosternal part was below the level of the aortic knuckle at the tracheal bifurcation in all cases. The histopathology revealed a simple multinodular goiter in eight of the nine patients (89%) and in one patient with papillary carcinoma. Five of the nine patients underwent intraoperative prophylactic tracheostomy due to tracheomalacia. CONCLUSIONS A long-standing goiter with deep (below the aortic knuckle) mediastinal extension and tracheal space compromise can be postulated to increase the likelihood of sternotomy.
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Affiliation(s)
- Mohamed E Ahmed
- Department of Surgery, Faculty of Medicine, University of Khartoum, PO Box 102, Khartoum, Sudan.
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31
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Phitayakorn R, Super DM, McHenry CR. An Investigation of Epidemiologic Factors Associated With Large Nodular Goiter. J Surg Res 2006; 133:16-21. [PMID: 16690367 DOI: 10.1016/j.jss.2006.02.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Revised: 02/17/2006] [Accepted: 02/20/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sporadic nodular goiter is a common problem in the United States and significant compressive symptoms may occur with progression to a critical size. METHODS Potential epidemiological variables associated with the development of large unilateral (> or = 50 g) and bilateral (> or = 100 g) nodular goiter were investigated including: age, gender, race, body mass index (BMI), family history of thyroid disease, pregnancy at time of diagnosis, insurance status, and tobacco or alcohol use. Data were obtained from an IRB-approved thyroid database and retrospective chart review of consecutive patients operated on for nodular goiter from 1990 through 2005. A univariate and multivariate analysis of epidemiological variables in patients with "large" versus "small" nodular goiter was completed. RESULTS Of the 488 patients operated on for nodular goiter, 113 (23%) were classified as "large," 43 with unilateral (mean 106 +/- 72 g) and 70 with bilateral enlargement (mean 173 +/- 92 g) and 375 (77%) were classified as "small," 179 with unilateral (18 +/- 10 g) and 196 with bilateral (37 +/- 24 g) enlargement. Based on univariate analysis, African-American race, age > or = 40 years, BMI > or = 30 kg/m2, and lack of insurance were associated with an increased risk of large nodular goiter (P < or = 0.001), whereas alcohol use was protective (P = 0.002). A multivariate analysis revealed that African-American race [adjusted odds ratio (adj. OR) 3.3, 95% CI = 2.0-5.4], age > or = 40 years (adj. OR 2.1, 95% CI = 1.2-3.8), and BMI > or = 30 kg/m2 (adj. OR 2.5, 95% CI = 1.5-4.0) were independently associated with large nodular goiter. No significant differences were observed in gender, family history of thyroid disease, pregnancy, or tobacco use (P > 0.1). CONCLUSIONS African-American race, obesity, and increasing age are independent risk factors for the development of large nodular goiter. These results may be helpful in determining how best to monitor patients with nodular goiter, with earlier intervention to help prevent progressive enlargement and its sequelae.
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Affiliation(s)
- R Phitayakorn
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio 44109, USA
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Li Pi Shan W, Hatzakorzian R, Sherman M, Backman SB. Upper airway compromise secondary to edema in Graves’ disease. Can J Anaesth 2006; 53:183-7. [PMID: 16434760 DOI: 10.1007/bf03021825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE We report an unusual case of upper airway compromise in a patient with Graves' disease. We speculate that this complication may be due, in part, to poorly controlled hyperthyroidism. CLINICAL FEATURES A 26-yr-old female suffering from Graves' disease underwent a total thyroidectomy. Awake fibreoptic intubation was attempted because of a large goiter and orthopnea. Upper airway edema impeded the passage of an armored 7.5 mm endotracheal tube. She was subsequently intubated awake with a regular 7.5 mm endotracheal tube under direct laryngoscopy over an Eschmann bougie. The patient was extubated in the operating room over a tube exchanger. Two hours later she developed stridor and upper airway obstruction. Using direct laryngoscopy, she was reintubated with difficulty because of upper airway edema. At this time, she manifested signs of thyrotoxicosis which were managed medically. On postoperative day three she underwent a tracheostomy after failing a trial of extubation. The upper airway was edematous with minimal vocal cord movement. On postoperative day nine the tracheostomy was downsized and the patient was sent home. The vocal cords were still edematous with minimal movement. Three weeks later, she demonstrated normal right vocal cord movement and weak left vocal cord movement, and the tracheostomy was decannulated. CONCLUSIONS Uncontrolled hyperthyroid patients with large goiters secondary to Graves' disease may develop edema of the upper airway. A high degree of vigilance for airway obstruction is necessary, with a carefully planned approach at each stage of the patient's hospital course to treat this potentially life-threatening situation.
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Affiliation(s)
- William Li Pi Shan
- Department of Anesthesia, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Lang BHH, Lo CY. Total thyroidectomy for multinodular goiter in the elderly. Am J Surg 2005; 190:418-23. [PMID: 16105529 DOI: 10.1016/j.amjsurg.2005.03.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2004] [Revised: 03/07/2005] [Accepted: 03/07/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Total thyroidectomy for multinodular goiter (MNG) is increasingly being performed for the elderly population and yet their perioperative and long-term outcomes remain unclear. METHODS A total of 279 patients who underwent total thyroidectomy for MNG in a university-based hospital during a 9-year period were analyzed according to their age at the time of operation. RESULTS The duration of operation (P=.023), intraoperative blood loss (P=.030), weight of resected thyroid glands (P<.001) and proportion of retrosternal goiter (P<.001) were significantly greater in the elderly group (>/=70 years) (n = 55), but the incidence of surgically related complications, including recurrent laryngeal nerve palsy and hypoparathyroidism, was similar. Postoperative pneumonia occurred more frequently in the elderly group (P=.034). The number of comorbidities tended to correlate with the length of hospital stay and long-term survival in elderly patients. CONCLUSIONS Total thyroidectomy for MNG in elderly patients had a similar perioperative outcome as their younger counterparts, but their long-term outcome is likely to be influenced by the number of comorbidities.
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Affiliation(s)
- Brian Hung-Hin Lang
- Division of Endocrine Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China
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34
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Carden KA, Boiselle PM, Waltz DA, Ernst A. Tracheomalacia and Tracheobronchomalacia in Children and Adults. Chest 2005; 127:984-1005. [PMID: 15764786 DOI: 10.1378/chest.127.3.984] [Citation(s) in RCA: 423] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Tracheomalacia and tracheobronchomalacia are disorders that are encountered in both pediatric and adult medicine. Despite increasing recognition of these disease processes, there remains some uncertainty regarding their identification, causes, and treatment. This article is intended to be a comprehensive review of both the adult and pediatric forms of the diseases, and includes sections on the historical aspects of the disorders, and their classification, associated conditions, histopathology, and natural history. We also review the various modalities that are used for diagnosis as well as the state of the art of treatment, including airway stent placement and surgical intervention.
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Affiliation(s)
- Kelly A Carden
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02446, USA
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35
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Bouaggad A, Nejmi SE, Bouderka MA, Abbassi O. Prediction of Difficult Tracheal Intubation in Thyroid Surgery. Anesth Analg 2004; 99:603-6, table of contents. [PMID: 15271749 DOI: 10.1213/01.ane.0000122634.69923.67] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The incidence of difficult endotracheal intubation (DEI) for patients undergoing thyroidectomy has rarely been studied, and evaluation of factors linked to DEI is limited to a few studies. We undertook this prospective study to investigate the incidence of DEI in the presence of goiter (an enlargement of the thyroid gland) and to evaluate factors linked to DEI. We studied 320 consecutive patients scheduled for thyroidectomy. DEI was evaluated by an intubation difficulty scale. The trachea was intubated by an unassisted anesthesiologist, and the intubation difficulty scale was calculated. A univariate analysis was performed to identify potential factors predicting DEI, followed by a multivariate analysis. DEI was reported in 17 patients. The rate of easy tracheal intubation was 36.9%; the rate for patients who had minor difficulty of intubation was 57.8%. Sex (male), body mass index, Mallampati class, thyromental distance, neck mobility, Cormack grade, cancerous goiter, and tracheal deviation or compression were identified in the univariate analysis as potential DEI risk factors. With multivariate analysis, two criteria were recognized as independent for DEI (Cormack Grade III or IV and cancerous goiter). We conclude that the large goiter is not associated with a more frequent DEI. However, the presence of a cancerous goiter is a major factor for predicting DEI.
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Affiliation(s)
- Abderrahmane Bouaggad
- Department of Anesthesiology and Intensive Care, CHU Ibn Rochd Casablanca 20000, Morocco.
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36
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Affleck BD, Swartz K, Brennan J. Surgical considerations and controversies in thyroid and parathyroid surgery. Otolaryngol Clin North Am 2003; 36:159-87, x. [PMID: 12803015 DOI: 10.1016/s0030-6665(02)00135-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The techniques of thyroid surgery have been fully elucidated in several surgical texts and atlases. This article discuss surgical pearls of thyroid and parathyroid surgery. We discuss preoperative, intraoperative, and postoperative considerations and controversies for both procedures.
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Affiliation(s)
- Brian D Affleck
- Department of Otolaryngology/Head and Neck Surgery, Lakenheath Hospital, 48 MDOS/SGOSL, RAF Lakenheath, APO AE 09464, UK
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Hegedüs L, Bonnema SJ, Bennedbaek FN. Management of simple nodular goiter: current status and future perspectives. Endocr Rev 2003; 24:102-32. [PMID: 12588812 DOI: 10.1210/er.2002-0016] [Citation(s) in RCA: 471] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The simple nodular goiter, the etiology of which is multifactorial, encompasses the spectrum from the incidental asymptomatic small solitary nodule to the large intrathoracic goiter, causing pressure symptoms as well as cosmetic complaints. Its management is still the cause of considerable controversy. The mainstay in the diagnostic evaluation is related to functional and morphological characterization with serum TSH and (some kind of) imaging. Because malignancy is just as common in patients with a multinodular goiter as patients with a solitary nodule, we support the increasing use of fine-needle aspiration biopsy (cytology). Most patients need no treatment after malignancy is ruled out. In case of cosmetic or pressure symptoms, the choice in multinodular goiter stands between surgery, which is still the first choice, and radioiodine if uptake is adequate. In addition to surgery, the solitary nodule, whether hot or cold, can be treated with percutaneous ethanol injection therapy. If hot, radioiodine is the therapy of choice. Randomized studies are scarce, and the side effects of nonsurgical therapy are coming into focus. Therefore, the use of the optimum option in the individual patient cannot at present be based on evidence. However, we are of the view that levothyroxine, although widely used, should no longer be recommended routinely for this condition. Within a few years, the introduction of recombinant human TSH and laser therapy may profoundly alter the nonsurgical treatment of simple nodular goiter.
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Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, DK-5000 Odense C, Denmark.
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Sharma ML, Beckett N, Gormley P. Negative pressure pulmonary edema following thyroidectomy. Can J Anaesth 2002; 49:215. [PMID: 11823408 DOI: 10.1007/bf03020501] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Rezig K, Diar N, Benabidallah D, Dardel A. [Goiter and pregnancy: a cause of predictable difficult intubation]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2001; 20:639-42. [PMID: 11530752 DOI: 10.1016/s0750-7658(01)00433-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
During pregnancy the thyroid undergoes several changes including altered function and gland enlargement. We describe the management of a 36-week pregnant woman presenting with upper-way obstruction secondary to tracheal compression by a large multinodular goitre. The patient was successfully managed with an awake fibreoptic intubation performed orally followed by a caesarean section and thyroidectomy as a combines procedure.
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Affiliation(s)
- K Rezig
- Service d'anesthésie-réanimation, CHI André Grégoire, 93150 Montreuil, France.
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Abstract
In summary, disease of the thyroid gland is common. Anaesthetists will be required to manage patients with hypothyroidism and hyperthyroidism and those requiring thyroidectomy. Since anaesthesia for thyroidectomy provides many challenges of airway management, the anaesthetist should pay particular attention to preoperative assessment of the airway and should be able to deal with acute airway complications in the perioperative phase.
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Affiliation(s)
- P A Farling
- Department of Anaesthetics, Royal Victoria Hospital, Belfast, UK
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