Abstract
Retrosternal extension of the goiter can cause compression of the trachea, esophagus and major blood vessels. Airway management is indeed a challenge in patients with airway obstructive signs and symptoms and it is based on the severity of the patient’s clinical symptoms, availability of airway equipments, familiarity and expertise. We encountered a patient with retrosternal goiter with tracheal compression, presented for surgery required pediatric Fiber-Optic Bronchoscope (FOB) for securing the airway. A 45 year female patient presented with a swelling in front of the neck for 6 months. Recently, she developed intermittent stridor which was aggravated by lying supine. In computed tomography, there was a retrosternal extension of thyroid gland into superior mediastinum causing tracheal compression and narrowing (80%). Awake fiber-optic intubation with paediatric FOB was used to secure the airway before induction of anaesthesia. Paediatric FOB can be useful to secure airway in patients with tracheal compression and narrowing.
Keywords: Retrosternal goiter, Tracheal compression, Stridor, FOB, Awake FOB, Tracheal narrowing
Introduction
Retrosternal extension of the goiter can cause compression of the trachea, esophagus and major blood vessels. Patients with retrosternal goiter can develop mediastinal mass syndrome (MMS) during the peri-operative period, characterized by cardio-respiratory decompensation [1]. Involvement of a multidisciplinary team comprising anesthesiologists, ENT surgeons and cardiovascular surgeons may be required for safe induction of anesthesia. Airway management is indeed a challenge in patients with airway obstructive signs and symptoms and it is based on the severity of the patient’s clinical symptoms, availability of types of equipments, familiarity and expertise [2, 3]. Various techniques had been described in the literature including direct laryngoscopy, awake-fibreoptic bronchoscope in a supine and semi-sitting position, rigid bronchoscopy and videolaryngoscopy [2, 4]. Awake fiberoptic is the gold standard for anticipated difficult airway. We encountered a patient with retrosternal goiter and tracheal compression, presented for surgery required pediatric Fiber-Optic Bronchoscope (FOB) for securing the airway.
Case Report
A 45 year old, female patient presented with a swelling in front of the neck for 6 months. The swelling was rapidly increasing in size and attained the size of an apple. She was complaining about difficulty in breathing and swallowing for the last 1 month. For the last one week, she developed intermittent noisy breathing which was aggravated by lying supine. A review of the past medical history reveals rheumatoid arthritis with steroid medications, pulmonary tuberculosis 12 years back and hypothyroidism under treatment. On examination, the swelling was moving with deglutition and not moving with protrusion of tongue. It was about 6 × 7 cms, and the lower border of the swelling was not palpable. Pemberton’s test was performed with monitor attached and found positive. Computed Tomography (CT) scan and Ultrasonogram (USG)-neck revealed enlarged thyroid gland with multiple ill-defined heterogeneously enhancing nodules within. There was a retrosternal extension into superior mediastinum causing tracheal compression and narrowing (80%). Fine needle aspiration cytology was suggestive of lymphocytic thyroiditis. Baseline laboratory parameters were within normal limits. She was planned for total thyroidectomy under general anaesthesia.
Awake oral fiberoptic intubation was decided to secure the airway (Plan A). Procedure was well explained to patient a day before surgery as well as on the day of surgery and consent was obtained. Standard fasting guidelines were followed. Standard ASA monitoring was attached. Nebulisation with 4% xylocaine and gargles with 10% lignocaine viscous (4 ml) were given to the patient. Dexmedetomidine infusion was started in preoperative area to allay anxiety. Intravenous glycopyrrolate 20mcg was administered before shifting the patient to the operating room. Oral endotracheal intubation was planned considering the need for post-operative mechanical ventilation in case of tracheomalacia. Airway block was not possible because of the large mass occupying the front of neck.
Patient was positioned supine in operating table with head end elevated to 30 degrees. Oral fiberoptic intubation was proceded with 6 mm internal diameter Endo-Tracheal Tube (ETT) loaded over the adult FOB. Glottis visualisation was achieved without difficulty. Intraluminal narrowing was found at < 1-2 cm level below the vocal cords. Further advancement of the scope was difficult because of the narrowing. Decision was taken to place the ETT below the vocal cords and just above the narrowing. Adult FOB was removed and 100% oxygen was administered for 2 min via ETT. Paediatric FOB was passed through the same ETT and the tracheal narrowing was negotiated easily. Then the ETT was advanced, and kept distal to the luminal narrowing above the carina. Muscle relaxants were administered and proceded for surgery. Surgery was uneventful. Before extubation, cuff leak test and fiberoptic examination of the trachea was done while gradually removing the ETT. No collapse of the tracheal wall was noticed and vocal cords were equally mobile. Patient was extubated successfully with no respiratory compromise. She was kept in the post-operative recovery room for the next 12 h for observation. Rest of the post-operative period was uneventful.
Discussion
Airway obstruction in patients with goiter may be due to direct invasion into trachea, pressure effect on tracheal rings and or tracheal deviation [5]. Airway management in patients with retrosternal goiter depends on the level, degree of obstruction, symptomatology and level of expertise. Sometimes, patients may be asymptomatic even with a huge thyroid mass with CT evidence of compressing trachea [6, 7]. In patients with retrosternal goiter difficulty can happen at all stages of the conduct of anesthesia [8] beginning from difficult bag-mask ventilation, difficult laryngoscopy-tracheal intubation, difficulties with ventilation because of tracheal compression/deviation and tracheomalacia postoperatively. And surgical access to the trachea is also difficult in case of “cannot ventilate, cannot intubate” situations. The degree and nature of the tracheal compression depend upon the primary disease itself and the duration of the goiter. Preoperatively performed pulmonary function test, i.e., flow-volume loop shows expiratory plateau. The usefulness of the USG in goiter is limited for assessment of the airway. CT scan of the neck and anterior mediastinum is commonly advised to look for the extent of goiter intrathoracically, compression of major airways, level of compression and the diameter of the airway at the compression level. However, the obstruction is dynamic, in the case of benign conditions of the thyroid, where the diameter of the airway at the level of obstruction varies with respiration, and it is not commonly measured by CT scan. Hence, preoperative evaluation of retrosternal goiter roughly gives idea about the airway compromise. This patient underwent awake fibreoptic-bronchoscopy 2 months before the surgery, which revealed 60% luminal compression for about 2 cm below vocal cords.
Awake intubation, awake Fiber-Optic Intubation (AFOI) and jet ventilation are the commonly preferred techniques of securing an airway in these patients. We preferred AFOI in our case to prevent airway collapse during the induction of anesthesia and to position the ETT distal to the obstruction. We used adult fiber-optic and tracheal lumen was too narrow to allow scope to pass through. Moreover, advancing larger diameter scope into the narrowed tracheal lumen may completely obstruct the airway in a spontaneously breathing patient. Forceful manipulation of the tube through stenosis may lead to bleeding, would lead to further difficulties. In this context, we decided to proceed with pediatric fiber-optic scope. We were able to safely negotiate the narrowed area of the trachea. The visualized area below the obstruction up to carina was normal. ETT was advanced over the fiber-optic scope and anesthesia was induced. In a prospective international expert opinion study, similar technique was advised by an expert for a patient with similar clinical profile[2]. Airway management in patients with tracheal narrowing is context-sensitive. Paediatric fiber-optic bronchoscope will be useful when securing airway management in patients with tracheal compression and significant narrowing.
Conclusion
Airway management in patients with tracheal compression is meticulous. Possibility of dynamic airway diameter changes should be kept in mind while interpreting radiographic images. Inclusion of paediatric fiber-optic bronchoscope in the airway cart should be considered while dealing these types of patients.
Acknowledgement
Not Applicable.
Funding
Not Applicable
Compliance with Ethical Standards
Conflict of interest
No potential conflict of interest relevant to this article is reported.
Footnotes
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