Management of a patient with tracheomalacia and supraglottic obstruction after thyroid surgery
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We describe an unusual combination of dynamic supraglottic, glottic, subglottic, and intrathoracic airway obstructions following a total thyroidectomy. These problems were anticipated, documented videographically, and managed preemptively.
Following a total thyroidectomy, we replaced the endotracheal tube with a laryngeal mask airway, namely, the LMA-Classic™, in a patient with symptomatic tracheal compression and probable obstructive sleep apnea. Spontaneous ventilation was observed bronchoscopically through the LMA-Classic. Supraglottic swelling, extraglottic collapse on inspiration, and intrathoracic collapse on expiration were documented prior to recovery. These observations were of sufficient concern to warrant reinsertion of the endotracheal tube and subsequent tracheal extubation over a tube exchanger. Thereafter, we provided face-mask continuous positive airway pressure using a Boussignac mask with an endotracheal ventilation catheter in situ.
Acute airway collapse following thyroid surgery is a rare and potentially serious complication. Diagnosis by conventional methods may be insensitive. Difficulties may not be apparent until the patient becomes distressed after tracheal extubation, and this circumstance will worsen airway compromise. In such a state, re-establishing the airway can become life-threatening. We describe the preemptive identification, physiologic manifestations, and management of the supraglottic and subglottic obstruction exemplified by this case.
KeywordsObstructive Sleep Apnea Continuous Positive Airway Pressure Total Thyroidectomy Laryngeal Mask Airway Spontaneous Ventilation
Prise en charge d’un patient atteint de trachéomalacie et d’obstruction supraglottique après une chirurgie de la thyroïde
Nous décrivons une combinaison inhabituelle d’obstructions dynamiques supraglottique, glottique, sous-glottique et intrathoracique des voies aériennes après une thyroïdectomie totale. Ces problèmes ont été anticipés, documentés par vidéo et pris en charge de façon préventive.
À la suite d’une thyroïdectomie totale, nous avons remplacé la sonde endotrachéale par un masque laryngé, le LMA-Classic™, chez un patient présentant une compression trachéale symptomatique et une apnée obstructive du sommeil probable. La ventilation spontanée a été observée par bronchoscopie via le LMA-Classic. Un œdème supraglottique, un collapsus extraglottique à l’inspiration et un collapsus intrathoracique à l’expiration ont été documentés avant le réveil. Ces observations étaient suffisamment préoccupantes pour justifier la réinsertion de la sonde endotrachéale suivie de l’extubation trachéale sur un échangeur de sonde. Par la suite, nous avons mis en place une ventilation à pression positive continue avec un masque facial de Boussignac et un cathéter endotrachéal de ventilation in situ.
Un collapsus aigu des voies aériennes après une thyroïdectomie est une complication rare mais potentiellement grave. Le diagnostic réalisé à l’aide des méthodes conventionnelles pourrait ne pas être suffisamment sensible pour détecter ce type de complication. Les difficultés peuvent être dissimulées jusqu’à ce que le patient s’agite après l’extubation trachéale, et une telle situation pourrait également compromettre davantage les voies aériennes. Dans un tel état, le rétablissement des voies aériennes peut devenir fatal. Nous décrivons l’identification préventive, les manifestations physiologiques et la prise en charge des obstructions supraglottiques et sous-glottiques illustrées par ce cas.
Symptomatic tracheal compression from thyroid enlargement is relatively rare in the developed world. Even in endemic areas, compression sufficient to result in post-thyroidectomy tracheomalacia is rare,1 , 2 while its very existence in the developed world is questioned.3 - 5 In this case report, we discuss the recognition and management of a patient with symptomatic tracheal compression and document supraglottic, glottic, subglottic, and intrathoracic airway obstruction following a total thyroidectomy. Photographs and video images were obtained and published with the written consent of the patient.
A 43-yr-old male with a thyroid goiter presented for total thyroidectomy. He was a 15-pack-yr smoker with recently diagnosed hypertension. On examination, he had a large neck circumference but a normal interincisor gap and thyromental distance, a full range of cervical and temporomandibular motion, and a modified Mallampati 2 oropharyngeal view. His body mass index was 36 kg·m−2, and he had clinical symptoms of obstructive sleep apnea (OSA), including witnessed snoring, apnea, and daytime somnolence. Preoperative pulmonary function testing and a sleep study had been requested, but the patient did not comply.
No further airway problems were noted during the hospital stay. One week later, nasal endoscopy revealed normal vocal cord movement. The pathology results showed papillary hyperplasia and degeneration as well as incidental papillary microcarcinoma.
Airway obstruction after thyroidectomy is a rare but serious complication2 , 3 , 7 which may lead to catastrophic consequences. The causes of airway obstruction specifically related to thyroid resection include postoperative wound hematoma, vocal cord palsy secondary to recurrent laryngeal nerve damage, laryngeal edema, tracheomalacia, hypocalcemia, and pneumothorax. Assessment of the larynx and trachea prior to extubation may predict the risk of postoperative airway obstruction and guide the optimal management strategy; however, the presence of an ETT and positive pressure ventilation may preclude such a diagnosis. Furthermore, tracheal examination must be performed in a manner that minimizes stimulation and coughing in the absence of an ETT.
In this report, an LMA-Classic was used in conjunction with an airway exchange catheter to facilitate the assessment of the airway and as a temporizing measure to assess the adequacy of spontaneous ventilation in the presence of supraglottic and subglottic obstruction. The use of the flexible bronchoscope through the LMA-Classic allowed controlled visualization and assessment of the vocal cords and the tracheal lumen. This was achieved during the spontaneous breathing while regulating the oxygen concentration and depth of anesthesia and ensuring that secretions did not obscure the view. This technique has been previously described.8 , 9
Evidence of tracheomalacia secondary to the thyroid goiter is largely limited to areas with endemic goiters, and it remains a rare diagnosis. A retrospective review from India by Agarwal et al. identified 28 (3.1%) of 900 patients undergoing a thyroidectomy who required treatment for tracheomalacia, with 26 (2.8%) receiving a tracheostomy.1 In another report from Sudan, 6 (5.8%) of 103 patients undergoing thyroid surgery for a large goiter had tracheomalacia, with 5 (4.8%) requiring a tracheostomy.2 These and several other studies indicate a link between a long-standing goiter and tracheomalacia.7 , 9 - 11 Conversely, Lacoste et al. followed a cohort of 3,008 patients undergoing thyroidectomy and found that none of the cases developed tracheal collapse after surgery.3 The main causes of postoperative respiratory obstruction were wound hematoma, bilateral recurrent laryngeal nerve palsies, and laryngeal edema.3 These findings were supported by several other reports.12 - 15
The physiological changes during spontaneous breathing in a patient with tracheomalacia, supraglottic edema, and OSA provide an interesting combination of features. Tracheomalacia occurs when tracheal cartilage becomes soft and weak and is unable to maintain its patency throughout the breathing cycle.10 , 16 , 17 During expiration, the intrathoracic pressure rises above the intraluminal pressure of the trachea, and in the absence of cartilaginous support, the trachea collapses, which reduces the airway cross-sectional diameter.16 - 18 In severe cases, the anterior wall can completely collapse onto the posterior wall. In contrast, the appearance of OSA is quite different. The upper airway narrows, particularly in the velopharyngeal region,19 , 20 and may collapse on inspiration during the sleep or recovery state when the pharyngeal muscles are hypotonic and negative intrathoracic pressures are generated to overcome upper airway resistance.21 This phenomenon was observed in this case where supraglottic collapse and downward displacement of the larynx were evident on inspiration (Fig. 4 and supplementary video). This case presented an interesting combination of airway abnormalities: OSA causing airway collapse on inspiration; tracheomalacia—primarily with extrathoracic involvement resulting in subglottic collapse on inspiration; and to a lesser degree, intrathoracic tracheal collapse on expiration. This situation was complicated further by supraglottic edema and paradoxical adduction of the vocal cords on inspiration.
We do not know the outcome had the patient been extubated without CPAP or an ETVC, and we do not contend that either the edema or the tracheomalacia resolved during the time these remained in place. However, this strategy did permit the stepwise withdrawal of support in a fashion that we believe had the highest probability of safe reversal, namely, the reinstitution or escalation of CPAP and tracheal reintubation.
In summary, this report describes a patient with documented supraglottic, subglottic, and intrathoracic airway obstruction, which was evident only with spontaneous ventilation following tracheal extubation. This condition was confirmed by bronchoscopic assessment through an LMA-Classic, which enabled proactive management with noninvasive CPAP to maintain airway patency. Access to the trachea was maintained with an ETVC left in situ to facilitate reintubation.
Funding for this publication was entirely with institutional resources.
Conflict of interest
There are no pertinent conflicts of interest relating to this report.
Supplementary material 1 (AVI 26817 kb)
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