|Year : 2008 | Volume
| Issue : 3 | Page : 328-330
Tracheomalacia: A Rare Complication After Thyroi dectomy
Dushyant Tripathi1, Indira Kumari2
1 Senior Resident, Department of Anesthesiology, R.N.T. Medical College, Udaipur - 313001, Rajasthan, India
2 Associate Professor, Department of Anesthesiology, R.N.T. Medical College, Udaipur - 313001, Rajasthan, India
|Date of Acceptance||25-Mar-2008|
|Date of Web Publication||19-Mar-2010|
Warden House, Jr. Girls Medical Hostel, M.B. Hospital Campus, Udaipur 313001 Rajasthan
Source of Support: None, Conflict of Interest: None
Tracheomalacia is weakness of tracheal wall caused by softening of supporting cartilage and hypotonia of myoelastic elements. In patients with huge thyroid, following thyroidectomy it is due to extrinsic compression by enlarged thyroid in which previously normal cartilage undergoes degeneration. We report a case of tracheomalacia following total thyroidectomy for malignant neoplasm of thyroid gland who was diagnosed and managed.
Keywords: Total thyroidectomy, Tracheomalacia, Bronchoscopy
|How to cite this article:|
Tripathi D, Kumari I. Tracheomalacia: A Rare Complication After Thyroi dectomy. Indian J Anaesth 2008;52:328-30
| Introduction|| |
Post operative causes of respiratory obstruction in patients with marked thyroid enlargement include local haemorrhages, bilateral recurrent nerve palsies, laryngeal edema and tracheomalacia. Tracheomalacia exists when the cartilaginous framework of trachea is unable to maintain airway patency  which may be either due to congenital immaturity of tracheal cartilage (primary tracheomalacia) or previously normal cartilage undergoes degeneration due to extrinsic compression by enlarged thyroid (secondary tracheomalacia)  . Diagnosis can be difficult and is often based on an assessment of the airway at bronchoscopy  Tracheomalacia can also be diagnosed by imaging studies(fluoroscopy and radiography , CT scanning and esophagography)  .It has been managed by tracheostomy , stent placement  and thoracoscopic aortopexy  .Last two are the latest recommendations for tracheomalacia management.
In this case report secondary tracheomalacia was the cause of upper respiratory obstruction following surgery performed in a patient with cancerous thyroid which was successfully managed by emergency tracheostomy.
| Case report|| |
A 52-year-old male, a known case of carcinoma thyroid of six month duration with secondaries in the neck was taken for total thyroidectomy with radical neck dissection. He was chronic smoker since 20 years, has stopped smoking one week back. On examination of the patient, a large immobile swelling with well defined margins presented anteriorly in the neck. There was no retrosternal extension in this patient. Airway grading was Mallampatti II. Cardiorespiratory assessment was normal with heart rate 76 /min, blood pressure of 140/80 mm of Hg. Heart sounds were normal. We didn't advised pulmonary function tests because this patient didn't have compressive symptoms , no pathology lung was seen in X-ray chest and breath holding time was 25 seconds.
Investigations revealed haemoglobin of 12.0 gm%, fasting blood sugar 96 mg%, serum creatinine 0.87 mg and ECG tracing was within normal limits. Chest Xray showed prominent bronchovascular markings. Thyroid function implied euthyroid state. X-ray of neck revealed compression& deviation of trachea. On indirect laryngoscopy both vocal cords were mobile.
Night before surgery 0.5 mg alprazolam was given by mouth. Patient was shifted to operation theatre and two intravenous lines were secured with 18-G cannula. ECG and pulse oximeter were connected. Radial artery was cannulated under local anaesthesia to monitor invasive blood pressure. Airway management cart was kept ready. Premedication included glycopyrrolate 0.2 mg, fentanyl 100 µg, ondansetron 8 mg& dexamethasone 16 mg IV.
After preoxygenation lidocaine hydrochloride 2% (without preservative) 1mg.kg -1 IV was given and anaesthesia was induced with propofol 2 mg.kg -1 IV. After confirming ventilation succinylcholine 2 mg.kg -1 was given intravenously and following IPPV patient was intubated with 8.5 mm ID cuffed portex endotracheal tube (ETT) effortlessly in first attempt. After confirming equal bilateral airentry ETT was fixed. Anaesthesia was maintained with oxygen in nitrous oxide, supplemented with isoflurane, vecuronium and propofol infusion. Infusion of nitroglycerine 50 mg in 500 ml of 5 % dextrose was started and calibrated to maintain the blood pressure in the range of 80 - 90 mm Hg(systolic).
All the vital signs were maintained during intraoperative period which lasted for 5 hours. On completion of surgery lidocaine hydrochloride 2% (without preservative) 1mg.kg -1 IV was given and patient was reversed with neostigmine, and glycopyrrolate in the doses of 2.5 mg and 0.4 mg respectively and extubation was done. On direct laryngoscopy movement of both vocal cords was normal. Immediately after extubation patient developed strider in spite of mobile vocal cords. Anticipating tracheomalacia we planned bronchoscopy on spontaneous respiration to confirm diagnosis& found that anterior wall of trachea was collapsed against the posterior wall at the level of 2nd& 3rd tracheal cartilage. Immediate reintubation was done with 7.5 mm ID cuffed ETT and emergency tracheostomy was performed. Patient was extubated post tracheostomy after thorough oropharyngeal and tracheostomy suction. Decannulation of tracheostomy was done after three weeks.
| Discussion|| |
In this case difficult intubation was anticipated because of huge swelling, radiological evidence of tracheal deviation and airway grading of Mallampatti II. So, the adjuvants for difficult intubation were kept ready. In our case against our anticipation intubation was not difficult. ,
Invasive blood pressure monitoring was done because hypotensive anaesthesia was planned to decrease intraoperative bleeding.
Multiple preoperative risk factors in a patient with large goiter like goiter for more than 5 years, preoperative recurrent laryngeal nerve palsy, significant tracheal narrowing and / or deviation, retrosternal extension, difficult tracheal intubation and thyroid cancer may be useful in predicting the need for planned tracheostomy following thyroidectomy  . The assessment of a respiratory flow volume loop is regarded as the best method of evaluating upper airway obstruction  . Planned tracheostomy has been performed in 80% patients who had at least four of the six risk factors and tracheomalacia was the most common indication and reported in 4.85% of patients after thyroidectomy for a large goitre 7 . In our report also tracheomalacia was the main indication for tracheostomy but planned tracheostomy was not done because of presence of only two preoperative risk factors.
Planned tracheostomy was done in anticipation of recurrent laryngeal nerve injury during dissection (gross distortion of anatomical landmarks) and tracheomalacia (due to large size of swelling)  . Contrary to this report our patient didn't have stridor preoperatively.
Bilateral recurrent nerve palsies were the indications for post operative tracheostomy  . Many times, tracheomalacia was not observed following thyroidectomy in patients with marked thyroid enlargement  .
Generally tracheostomy is performed on the basis of clinical judgement  . The definitive method of diagnosis for tracheomalacia is bronchoscopy and during bronchoscopy the anterior wall can be observed to collapse against the posterior wall as was also observed in our patient and tracheostomy was done after confirmation of diagnosis by bronchoscopy because thyroidectomy was done by ENT surgeon. It was easy to perform bronchoscopy for confirmation of tracheomalacia, immediately before doing tracheostomy. Tracheomalacia is a known but rare complication following thyroidectomy in patients with enlarged thyroid and in this case tracheostomy was performed after confirmation of diagnosis in contrast to the planned tracheostomy which is routinely done in the presence of preoperative risk factors.
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