Airway management is large thyroid tumors

Case Report

Airway management is large thyroid tumors5

Honey Ashok a,*, Prerana Rao b, Yedahalli Seetharama Nagamani b

aConsultant & Co-ordinator, Department of ENT-Head & Neck Surgery, Apollo Hospitals, No 154/11,

Opposite Indian Institute of Management, Bannerghatta Road, Bangalore 560076, IndiabRegistrar, 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 themost 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 ofOtolaryngologists of India (AOI) in January 2014, Mysore.* Corresponding author. Tel.: þ91 (0) 9945510365; fax: þ91 (0) 8041463151.E-mail addresses: [email protected], [email protected] (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 ) 1e3

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.2014.02.0020976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

the whole neck measuring around 15 � 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 neckwas 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,withmarkednarrowing 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

wereengulfedby the tumorwithsignsof 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.

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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 ManagementGuidelines for patients with thyroid nodules and differentiatedthyroid cancer. Thyroid. 2009;19.

2. Shaha AR. Airway management in anaplastic thyroidcarcinoma. Laryngoscope. 2008 Jul;118:1195e1198.

Fig. 4 e CT scan coronal view.

Fig. 5 e Post-operative.

Fig. 6 e Tracheostomy.

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Airway management is large thyroid tumors

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