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CASE REPORT
Year : 2008  |  Volume : 52  |  Issue : 3  |  Page : 328-330 Table of Contents     

Tracheomalacia: A Rare Complication After Thyroi dectomy


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 Acceptance25-Mar-2008
Date of Web Publication19-Mar-2010

Correspondence Address:
Indira Kumari
Warden House, Jr. Girls Medical Hostel, M.B. Hospital Campus, Udaipur 313001 Rajasthan
India
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Source of Support: None, Conflict of Interest: None


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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

How to cite this URL:
Tripathi D, Kumari I. Tracheomalacia: A Rare Complication After Thyroi dectomy. Indian J Anaesth [serial online] 2008 [cited 2017 Aug 19];52:328-30. Available from: http://www.ijaweb.org/text.asp?2008/52/3/328/60644


   Introduction Top


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 [1] 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) [2] . Diag­nosis can be difficult and is often based on an assess­ment of the airway at bronchoscopy [1] Tracheomalacia can also be diagnosed by imaging studies(fluoroscopy and radiography , CT scanning and esophagography) [3] .It has been managed by tracheostomy , stent placement [3] and thoracoscopic aortopexy [4] .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 Top


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 Top


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. [5],[6]

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 [7] . The assessment of a respiratory flow volume loop is regarded as the best method of evaluating upper airway obstruction [8] . 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) [6] . Con­trary to this report our patient didn't have stridor pre­operatively.

Bilateral recurrent nerve palsies were the indica­tions for post operative tracheostomy [5] . Many times, tracheomalacia was not observed following thyroidec­tomy in patients with marked thyroid enlargement [5] .

Generally tracheostomy is performed on the ba­sis of clinical judgement [7] . 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.

 
   References Top

1.Griffiths, et al. Tracheomalacia and breath holding - a case report. Archives Disease Child 2000 ; 83 : 340 - 341.  Back to cited text no. 1      
2.Thomas H, Cogobill, Frederick A, et al. Primary Tracheomalacia. Ann Thorac Surg 1983;35 : 538-541.  Back to cited text no. 2      
3.Iran M, Ayvaz S, Basaran UN. Treatment of tracheomalacia with Palmaz stent : a case report Folia Med (Plov div) 2005;47:58-60.  Back to cited text no. 3      
4.Dave S, Currie BG. The role of aortopexy in severe tracheomalacia. J Pediatr Surg 2006;533-7.  Back to cited text no. 4      
5.Lacoste L, Gineste D, Karayan J, et al. Airway complica­tions in thyroid surgery. Am J Otorhinolaryngo 1993;102: 441-46.  Back to cited text no. 5      
6.Hegde R, Gurumurthy T, Ashwini T. An unusual case of recurrent malignant thyroid with haematoma causing res­piratory obstruction and its management-a case report. Indian J Anaesthesia 2005; 49:49-50.  Back to cited text no. 6      
7.Abdel Rahim AA, Ahmed ME, Hassan MA. Respiratory complications after thyroidectomy and the need for tra­cheostomy in patients with a large goiter. Br J Surg 1999; 86: 88-90.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Gittoes NJL, Miller MR, Daykin J, Sheppard MC , Franklyn JA. Upper airways, obstruction in 153 consecutive pa­tients presenting with thyroid enlargement. BMJ 1996; 312:484.  Back to cited text no. 8      




 

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