Published on March 14, 2014
Airway management is large thyroid tumors
Case Report Airway management is large thyroid tumors5 Honey Ashok a, *, Prerana Rao b , Yedahalli Seetharama Nagamani b a Consultant & Co-ordinator, Department of ENT-Head & Neck Surgery, Apollo Hospitals, No 154/11, Opposite Indian Institute of Management, Bannerghatta Road, Bangalore 560076, India b Registrar, Department of ENT-Head & Neck Surgery, Apollo Hospitals, No 154/11, Opposite Indian Institute of Management, Bannerghatta Road, Bangalore 560076, India a r t i c l e i n f o Article history: Received 2 January 2014 Accepted 12 February 2014 Available online xxx Keywords: Thyroid Papillary Airway Tracheostomy a b s t r a c t Papillary Carcinomas of the thyroid are slow growing and least aggressive of all thyroid tumors. These tumors when large can cause compression of the trachea and symptoms of dyspnea and stridor. Airway management is of crucial importance not only for symp- tomatic relief, but also for airway control pre-operatively till the deﬁnitive diagnosis and treatment is planned. The dilemmas faced in airway management are many folds considering the tumor proﬁle and patient compliance. It plays a crucial role in ﬁnal deci- sion making. Papillary thyroid carcinoma prognosis is good. Distant metastasis is also not a contraindication for treating the primary. Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Papillary carcinoma of the thyroid gland is the most common, accounting for 75% of all thyroid malignancies, and the most indolent with a survival rate of 98%.1 Usually it presents as hypoechoic nodules in the thyroid gland. It is very rare for papillary carcinoma to present with large neck mass compromising airway and invading surrounding tissues. These features are more characteristic of anaplastic thyroid carcinoma. There are many challenges in treating such patients. 1) Airway access to overcome obstruction. 2) Anesthesia concerns. 3) Surgical clearance (as there is soft tissue invasion). 4) Preservation of the recurrent laryngeal nerve. 5) Preserving parathyroids to prevent post-operative hypocalcaemia. 6) Hypopharyngeal and cervical oesophageal integrity and continuity. 2. Case report A 76-year-old male patient presented with stridor. He gives history of neck swelling noticed since three years gradually increasing in size, history of dysphagia and hoarseness of voice since one year. Stridor is since one week. On examina- tion there was a large swelling in front of the neck covering 5 This case has not been presented in any meeting. Planned for a poster presentation for the National Conference of Association of Otolaryngologists of India (AOI) in January 2014, Mysore. * Corresponding author. Tel.: þ91 (0) 9945510365; fax: þ91 (0) 8041463151. E-mail addresses: firstname.lastname@example.org, email@example.com (H. Ashok). Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 Please cite this article in press as: Ashok H, et al., Airway management is large thyroid tumors, Apollo Medicine (2014), http:// dx.doi.org/10.1016/j.apme.2014.02.002 http://dx.doi.org/10.1016/j.apme.2014.02.002 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
the whole neck measuring around 15 Â 18 cm in size, hard in consistency, extending from the chin to the clavicle and to the posterior triangle of the neck laterally. Patient was main- taining saturation of 94% on room air, with persistent tachypnea and restlessness. Patient was shifted to the ICU for observation. CT scan neck was done to ascertain the extent of the tumor and assess the airway. CT scan showed a large tumor with ill- deﬁned margins due to inﬁltration into the soft tissue with gross distortion of the airway starting from the oropharynx to the lower cervical trachea, with marked narrowing and shift to the left. The internal jugular vein on the left showed large tumor thrombi occluding the whole length of the vein. The common carotid artery and the internal and external carotid were engulfed by the tumor with signs of inﬁltration (Figs. 1e6). The immediate concern was to have access to the airway. Awake ﬁbre optic bronchoscopic intubation was done by the pulmonologist, size 7 endotracheal tube was inserted. FNA revealed Papillary carcinoma. Planning the further course of action was tricky. Getting a permanent accessible airway was difﬁcult as we couldn’t have retained the endotracheal tube for long as it would get clogged with crusts and secretions even with the stringent measures of cleaning, suctioning and nebulization. Tracheostomy was difﬁcult due to the size of the tumor. Even if we had gone through the tumor for the tracheostomy, retaining a patent tracheostoma through the tumor would be difﬁcult due to tumor bleed, tumor extending into the stoma and blocking it, accidental displacement of tube making it unsafe and changing the tracheostomy tube would be difﬁ- cult. Have a safe tracheostoma was the ﬁrst priority. The tumor was inoperable considering the extent of the disease and the possibility of distant metastasis. Metastatic work up was not possible considering the intubated status of the patient and considering the extent of the primary disease it was likely that he had distant metastasis. Also it was not worth taking the risk of shifting the patient as the disease being papillary carcinoma distant metastasis wouldn’t alter the plan of treatment. Given the grim circumstances the relatives were explained about the diagnosis and status of the patient and the treat- ment options and the chances of survival. In 2 days of intubation patient was taken up for surgery. On table the anesthetist felt resistance in ventilating and there was sudden drop in oxygenation. Urgent tracheostomy was done through a lateral approach where the trachea was the most superﬁcial considering the size of the tumor. The airway was secured with no hypoxia damage to the patient, trache- ostomy tube was ﬁxed with stay sutures to prevent accidental dislodgement. Fig. 1 e Pre-operative. Fig. 2 e Per-operative photo showing inﬁltration of the carotids. Fig. 3 e CT scan neck sagittal view. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e32 Please cite this article in press as: Ashok H, et al., Airway management is large thyroid tumors, Apollo Medicine (2014), http:// dx.doi.org/10.1016/j.apme.2014.02.002
On exposure the tumor was found to inﬁltrate the strap muscles, sternocleidomastoid, the prevertebral muscles, ca- rotid sheath, common e external and internal carotid arteries were thickened and involved by the tumor which was shaved from the adventitia, external carotid was ligated. Laryngeal framework, trachea and pharynx also showed inﬁltration. Post-operative large dose scan with ablation done with I 131 was given. There were multiple metastatic foci in the lungs and bones. Patient is on Ryle’s tube feeds and on tra- cheostomy. Right vocal cord is ﬁxed and left is mobile, with phonatory gap and minimal aspiration. 3. Discussion Papillary carcinomas rarely causes respiratory distress as they are slow growing. Anaplastic carcinomas usually are fast growing and cause inﬁltration into the surrounding structures causing respiratory symptoms and airway access and main- tenance becomes difﬁcult.2 Airway management for these patients depend on the extent of distant disease and the family’s understanding of the advanced nature of the disease and the palliative efforts. Decision regarding active manage- ment depends on tumor factors like pathology, staging, sur- vival rate and overall prognosis. Conﬂicts of interest All authors have none to declare. Acknowledgment We would like to acknowledge Dr Chandrashekar’s contribu- tion in managing the case. r e f e r e n c e s 1. Revised American Thyroid Association Management Guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19. 2. Shaha AR. Airway management in anaplastic thyroid carcinoma. Laryngoscope. 2008 Jul;118:1195e1198. Fig. 4 e CT scan coronal view. Fig. 5 e Post-operative. Fig. 6 e Tracheostomy. a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1 e3 3 Please cite this article in press as: Ashok H, et al., Airway management is large thyroid tumors, Apollo Medicine (2014), http:// dx.doi.org/10.1016/j.apme.2014.02.002
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Papillary Carcinomas of the thyroid are slow growing and least aggressive of all thyroid tumors. These tumors when large can cause compression of the ...
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