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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 138-141

Anesthetic management of total thyroidectomy and partial sternotomy for a case of retrosternal goiter


Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Submission06-Jun-2020
Date of Acceptance18-Jun-2020
Date of Web Publication09-Oct-2020

Correspondence Address:
Dr. Gokuldas Menon
Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_40_20

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  Abstract 


The anaesthetic management of retrosternal thyroid swellings has many associated problems. Positioning and induction may cause severe cardiorespiratory decompensation. Intubation may be difficult and may require all the gadgets for difficult intubation procedure. Rarely patients may require cardiopulmonary bypass to save life. Extubation may be difficult in patients with tracheomalacia. Post-operatively patients may require tracheostomy and ventilatory support. This is a case report outlining successful management of a patient with retrosternal goiter who underwent total thyroidectomy following partial sternotomy.

Keywords: CMAC laryngoscope, cuff leak test, fiberoptic bronchoscopy, retrosternal goiter, sternotomy, thyroidectomy Airway, CMAC, cuff leak test, fiber-optic bronchoscopy, goiter, intubation, retrosternal, sternotomy


How to cite this article:
Menon G, Kumar P, Rahman AA, Nair SM, George M, Issac E. Anesthetic management of total thyroidectomy and partial sternotomy for a case of retrosternal goiter. Amrita J Med 2020;16:138-41

How to cite this URL:
Menon G, Kumar P, Rahman AA, Nair SM, George M, Issac E. Anesthetic management of total thyroidectomy and partial sternotomy for a case of retrosternal goiter. Amrita J Med [serial online] 2020 [cited 2020 Nov 1];16:138-41. Available from: https://www.ajmonline.org.in/text.asp?2020/16/3/138/297558




  Introduction Top


Retrosternal goiter (RSG) is an enlarged thyroid gland which extends below the clavicle into thorax. Goiter has a 3:1 female predominance, with the highest incidence (1 in 2000) reported in women between 5th and 6th decades of life. The incidence of RSG is reported to be 0.1%–21% of thyroidectomies. This wide variation in the incidence may be due to the wide variety in the clinical classification.[1]

RSG is defined as[2],[3]

  1. Any part of the thyroid extending below the thoracic inlet with the patient in the surgical position.
  2. tMore than 50% of thyroid in the thoracic cavity
  3. Thyroid extending to the level of the fourth thoracic vertebra on chest x ray and
  4. Thyroid extending to the aortic arch


Based on the anatomical location RSG may be right or left, anterior or posterior.[4] The need for sternotomy is based on the CT image - the position and depth of the swelling - and clinical findings.

Pembertons sign indicates the compression of vascular structures in the thoracic inlet and warrants urgent treatment. The patient is to lift both his outstretched arms above his head. A positive sign can be visualized by marked plethora over the face which indicates the compression of the jugular veins.[5]

Although contrast-enhanced CT provides excellent visualization of neck and mediastinal structures, it may be contraindicated in large goiter since the use of iodine may induce hyperthyroidism.[6]

All patients with RSG undergoing surgery need an endocrinology evaluation to optimize the thyroid status and ENT consultation for the assessment of vocal cords and airway.[6] A proper plan of anesthesia and surgery are made by consultation between anesthesiologists, general surgeons, and cardiothoracic surgeons.[6]

The surgical approach for RSG depends on the anatomical location. A cervical approach is enough for a tumor above the arch of the aorta, whereas manubriotomy is needed if tumor extends below the arch of aorta to the pericardium. Sternotomy is required if RSG lies below the right atrium.[7]Compressive symptoms like cough, dyspnea, stridor, choking, and dysphagia are indications for the surgery.[6],[7]

Mediastinal mass syndrome (MMS) can occur intraoperatively from positioning of patients to the post operative period. MMS is due to compression of the trachea, bronchus and major blood vessels in the mediastinum. MMS result in acute respiratory or cardio vascular decompensation. Patients are classified into three risk groups according to the clinical symptoms and diagnostic findings. Safe – Asymptomatic patients. Unsafe - Patients with symptoms and diagnostic findings. Uncertain - Asymptomatic patients with CT findings or patients with moderate symptoms. The patient in our case belonged to the uncertain group.

High risk factors for anaesthesia include the presence of tracheal compression more than 50%, posterior mediastinal extension and restrictive/ obstructive patterns on pulmonary function tests. [7] Previous studies have shown that patients who had cardiorespiratory symptoms preoperatively are at higher risk of cardiorespiratory decompensation intraoperatively.[7]

Availability of rigid bronchoscopy with jet ventilation would offer rescue in the event of loss of airway control. Cardiopulmonary bypass would be life-saving in the event of acute cardiorespiratory decompensation.[8]


  Case Report Top


A 47 year-old male with a height of 170 cm and a weight of 74 Kg, who underwent left hemithyroidectomy 25 years back, presented with complaints of nonproductive cough for 3 months, weight loss of nearly 5 kg, and decreased appetite. The patient had a recent dengue infection for which he received treatment. He was clinically and biochemically euthyroid (TSH: 3.06 IU/ml; T4:1.97 ng/dl). He had no signs of dyspnea at rest or on exertion, no history of dysphagia to solid or liquid food, no history of hoarseness of voice or stridor, and no features of hypo/hyperthyroidism. He had no other comorbidities. On clinical examination, the patient was found to have a tracheal deviation to the right side which was confirmed on chest radiograph film [Figure 1]. The swelling was larger in size on the left side of the neck, the lower border of the swelling was not palpable, a dull note was felt on percussion over the sternum and there were no palpable neck lymph nodes. Pemberton's sign was negative. No visible/engorged veins were seen on the face, neck, or chest.
Figure 1: X-ray chest showing deviation of trachea to the right side

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Ultrasound examination of the neck showed the right lobe measuring 11 mm × 16.2 mm × 37.3 mm and the left lobe measuring 19 mm × 31.5 mm × 60 mm. The thyroid gland appeared enlarged with a retrosternal extension on the left side. No significant cervical adenopathy was seen.

CT chest [Figure 2] showed thyroid nodules on both lobes, tracheal compression of > 50% and tracheal deviation to the right. In addition, there was a compression of the left brachiocephalic vein. The thyroid swelling extended from the root of the neck superiorly to the arch of aorta inferiorly.
Figure 2: Computed tomography chest showing tracheal compression

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Electrocardiography (ECG) and pulmonary function tests were within the normal limits, and indirect laryngoscopy showed normal structure and function of the vocal cords.

Preoperative laboratory investigations were unremarkable.

The patient was reviewed by an endocrinologist and a cardio thoracic surgeon. A high-risk informed consent was taken explaining all the possible intraoperative and postoperative complications.

The patient was given routine premedications: Metoclopramide, Pantaprazole and Alprazolam. Inside the OT, standard ASA monitors were connected and the left radial artery was cannulated.

Since there was severe deviation of trachea toward right side and tracheal compression, difficult intubation was anticipated. C-MAC video laryngoscope and fiber optic bronchoscope were kept ready.

The patient was very cooperative. A check laryngoscopy done showed the tip of the epiglottis.

The patient was preoxygenated for 3 minutes and was induced with 0.2 mg Glycopyrrolate, 2 mg Midazolam, 140 mcg Fentanyl, and 150 mg Propofol. After confirming waveform capnography, patient was paralysed with 8 mg Vecuronium followed by intermittent positive pressure ventilation. He was then given 1.5 mg/kg Lignocaine two minutes before intubation. Patient was intubated with a flexometallic tube using CMAC video laryngoscope. The right subclavian artery was cannulated using a triple lumen catheter.

General anesthesia was maintained with fentanyl, oxygen, isoflurane and vecuronium. The patient received 9 mg of iv morphine before sternotomy.

Post induction, the patient had severe hypotension which responded to adequate hydration and noradrenaline infusion.

Kocher's collar skin crease incision was made and a midline vertical incision, about 7 cm long, was made over the sternum extending from the cervical incision downward. Partial sternotomy was done. Retrosternal extension [Figure 3] of about 6 cm was identified and excised.
Figure 3: Photos showing partial sternotomy

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Patient was stable with hydration and minimal inotropic support with noradrenaline. He was extubated after a negative cuff leak test to rule out tracheomalacia.

The patient was shifted to the ICU and nursed in 30° propped up position. He developed no signs of stridor, breathlessness, or desaturation postoperatively and was shifted out of ICU the next day. The patient was discharged on the fourth postoperative day.


  Discussion Top


RSG can cause compression of the tracheobronchial tree, the arch of aorta, the pulmonary arteries, the superior vena cava, and the heart leading to cardiorespiratory decompensation. Patients may have cough, stridor, breathlessness during exertion and on lying flat.[9] Our patient had persistent dry cough for about 3 months but did not manifest any other pressure symptoms. In addition, Pemberton's sign was negative.

The CT scan accurately measures the size and site of the swelling, compression of mediastinal structures and involvement of lymph nodes. Therefore, the CT scan is vital in planning the airway management.

The problems associated with RSG include cardiorespiratory decompensation, difficult intubation, increased blood loss, prolonged operating time, and postoperative tracheomalacia.[9]

General anesthesia with endotracheal intubation is preferred in RSG surgery. In patients with huge goiters, total airway obstruction may occur when muscle tone decreases during induction of general anesthesia. Awake preoperative assessment of the airway using Macintosh/CMAC Video laryngoscope may be useful. Difficult cases may require awake fiber-optic intubation.

Preinduction assessment of the airway was done using the Macintosh laryngoscope and intubation was uneventful with the assistance of a CMAC video laryngoscope. Some patients may require awake fiberoptic intubation.[10] A dreaded intra-operative complication is cardio-respiratory decompensation. Patients require adequate hydration and possibly inotropic support to maintain haemodynamic stability. In severe cases cardio pulmonary bypass may be life saving.[10]

Post-operative complications include hematoma formation, recurrent laryngeal nerve palsy, tracheomalacia, dysphonia, laryngeal edema, hypocalcemia, nausea and vomiting, deep vein thrombosis, and wound infection.[7] Prolonged compression of the trachea can lead to tracheomalcia. If it occurs patient may require tracheostomy or tracheal stenting. Our patient did not have any postoperative complications and was shifted out of the ICU the next day.


  Conclusion Top


A comprehensive history, a thorough clinical examination, and a preoperative review of patient's CT scan of the airway are necessary to avoid any untoward complications perioperatively. In addition, a patient presenting with RSG also warrants a clear plan for airway management and intubation. The anesthesiologist must be prepared to deal with acute perioperative airway complications and must collaborate with the general surgeon and the cardiothoracic surgeon to ensure a good postoperative outcome for the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Larry Jameson J, De Groot L. Endocrinology: Adult and Paediatric. 7th ed.. Philadelphia: Elsevier, Saunders; 2016. p. 1399-416.  Back to cited text no. 1
    
2.
Huins CT, Georgalas C, Mehrzad H, Tolley NS. A new classification system for retrosternal goitre based on a systematic review of its complications and management. Int J Surg 2008;6:71-6.  Back to cited text no. 2
    
3.
Dempsey GA, Snell JA, Coathup R, Jones TM. Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. Br J Anaesth 2013;4:594-9.  Back to cited text no. 3
    
4.
Cvasciuc IT, Fraser S, Lansdown M. Retrosternal goitres: A practical classification. Acta Endocrinol (Buchar) 2017;13:261-5.  Back to cited text no. 4
    
5.
Jukic T, Kusic Z. Pemberton's sign in patient with substernal goitre. J Clin Endocrinol Metab 2010;95:4175.  Back to cited text no. 5
    
6.
Hardy RG, Bliss RD, Lennard TW, Balasubramanian SP, Harrison BJ. Management of retrosternal goitres. Ann R Coll Surg Engl 2009;91:8-11.  Back to cited text no. 6
    
7.
Manouchehr A, Mohammed R.A, Fereshteh M., Haniye D, Yasaman S. An investigation into symptoms, diagnosis and treatment complications in patients with retrosternal goitre. Journal of Family Medicine and Primary Care. 2018;7:224-9.  Back to cited text no. 7
    
8.
Tan PC, Esa N. Anaesthesia for massive retrosternal goitre with severe intrathoracic narrowing: The challenges imposed-a case report. Korean J Anesthesiol 2012;62:474-8.  Back to cited text no. 8
    
9.
Kamath KS, Naik SA, Pratiksha NP. Retrosternal goitre-an anaesthetic challenge-a case report. J Clin Diagnostic Res 2019;13:01-3.  Back to cited text no. 9
    
10.
Kurdi MS, Shaikh SI. Trekking through a huge goitre with retrosternal extension. Med Innovatica 2013;2:105-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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