DOI: 10.14260/jemds/2014/2936
CASE REPORT
J of Evolution of Med and Dent Sci/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 3/ Issue 27/July 07, 2014 Page 7563
DELAYED STRIDOR FOLLOWING THYROID SURGERY: A CASE REPORT
Syed Fazal Mahmood1, Sampathilla Padmanabha2, Harish Hegde3, Santhosh K. Gouroji4HOW TO CITE THIS ARTICLE:
Syed Fazal Mahmood, Sampathilla Padmanabha, Harish Hegde, Santhosh K. Gouroji. Delayed Stridor following Thyroid Surgery: A Case Report. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 27, July 07; Page: 7563-7566, DOI: 10.14260/jemds/2014/2936
ABSTRACT: The complications following thyroid surgery are rare due to better preoperative
preparations and proper surgical techniques; however, complications like hematoma formation and recurrent laryngeal nerve injury are known to cause airway obstruction and can be fatal. We report a case of a 52 year old euthyroid patient, with preoperative diagnosis of papillary carcinoma of thyroid who underwent total thyroidectomy. In this patient both intra operative and immediate post- operative period was uneventful, but the patient developed life threatening airway obstruction after 24 hours of thyroidectomy, to maintain the airway patient required re-intubation, and re-exploration of the neck was done under general anesthesia. As airway obstruction persisted on trial extubation, tracheostomy was done. In this case both hematoma formation and damage to recurrent laryngeal nerve were suspected as causes of the stridor.
KEYWORDS: Thyroidectomy, Stridor, Hematoma, Recurrent laryngeal nerve palsy.
INTRODUCTION: The location of the thyroid gland in relation to the airway makes thyroidectomy a
challenge for both anesthesiologist and surgeon. Although the morbidity and mortality of thyroid surgery have decreased markedly over past century technical complications such as recurrent laryngeal nerve injury, hypothyroidism, superior laryngeal nerve injury, bleeding and wound infection still occur.1 Hematoma formation and recurrent laryngeal nerve injury are more serious and
can be fatal. The incidence of recurrent laryngeal nerve injury during thyroid surgery is found to be higher during re-exploration, Graves’ disease and carcinoma procedures.2
Here we are presenting a case where the patient developed stridor following total thyroidectomy. In this patient immediate post-operative period was uneventful, but 24hours after the surgery patient developed life threatening airway obstruction. The patient required emergency intubation, re-exploration of neck under general anesthesia and later required tracheostomy as there was persistent airway obstruction.
CASE REPORT: A 52 year old female weighing 40 kgs presented with thyroid swelling of 6 months
duration. The swelling was confined to neck and there was no retrosternal extension. There were no symptoms or signs suggestive of hypo or hyperthyroidism and pressure effects on trachea.
Thyroid function tests and routine investigations were within normal limits. Preoperative indirect laryngoscopy showed normal vocal cord movements. The x-ray of the neck did not reveal any deviation or compression of the trachea. Preoperative fine needle aspiration cytology was suggestive of a papillary carcinoma of thyroid.
Written and informed consent was taken prior to surgery, and the risks involved with surgery were explained.
DOI: 10.14260/jemds/2014/2936
CASE REPORT
J of Evolution of Med and Dent Sci/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 3/ Issue 27/July 07, 2014 Page 7564 In operation theatre patients pulse rate was 86 per min, regular in rhythm and blood pressure 120/70mmHg. Peripheral intravenous catheter secured, inj. Fentanyl 75mcg was given intravenously. Induction of anesthesia was performed with Propofol 100mg IV and intubation was facilitated with suxamethonium 75 mg IV, 7.0mm armored cuffed orotracheal tube was placed, Anesthesia was maintained with N2O: O2 and sevoflurane. Vecuronium was used as muscle relaxant.
Total thyroidectomy was performed; the surgery was uneventful and lasted for 3 hours. At the end of surgery, neuromuscular blockade was reversed with inj. Neostigmine 2mg and glycopyrollate 0.4mg IV, on extubation patient was responding to verbal commands. Vocal cord movements were normal on direct laryngoscopy. After extubation patient was shifted to post- operative ward and was monitored with oxygen therapy.
Next day morning patient had mild hoarseness of voice but was comfortable and maintaining SpO2 of 96% on room air, there was no neck swelling, suction drain contained 10 ml of blood. By
noon she developed breathing difficulty, on examination patient was restless, and there was chest in-drawing. Her pulse rate was 114 per minute and blood pressure 150/90mm of Hg, Respiratory rate was 38 per min, inspiratory stridor was present, Spo2 dropped to 80% on room air, immediate oxygen supplementation via face mask improved SpO2. She was shifted to operation theatre for
re-exploration under general anesthesia.
On exploration multiple blood clots were found and one large clot 4x3 cms was found compressing the trachea in cricothyroid area, blood clots were removed, hemostasis was achieved, drain was placed and wound closed. Patient was shifted to ICU with endotracheal tube in situ with oxygen therapy.
Elective extubation was planned next day using Cooks airway exchange catheter. After extubation stridor persisted, direct laryngoscopy was done and evidence of injury to bilateral recurrent laryngeal nerve palsy was present.
Oxygenation was maintained using cooks airway exchanger and Tracheostomy was performed under monitored anesthesia care with regional block.
Following tracheostomy patient’s condition improved.
DISCUSSION: The complications following thyroidectomy include hematoma, recurrent laryngeal
nerve injury, hypocalcaemia, infection and superior laryngeal nerve injury. The answer to the complications following thyroid surgery was found by Dr. Theodor Kocher, who is a Nobel Prize laureate3.Postoperative complications decrease with the experience of the surgeon and increase with
reoperations and extensive disease.4
Total airway obstruction may progress once the critical compression occurs in the compartment below the strap muscles. This leads to compression of the trachea.5 Routine drain
placement after thyroid surgery is not necessary nor is it effective in decreasing the rate of postoperative complications.6 It is difficult to predict risk for development of hematoma after thyroid
surgeries, and require intense post-operative monitoring and immediate intervention following development of hematoma.7 However the time interval to the development of hematoma has been
reported to be within 24 hours.5 Hence observation of patient in high dependent area is
recommended for 24 to 48 hours.
DOI: 10.14260/jemds/2014/2936
CASE REPORT
J of Evolution of Med and Dent Sci/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 3/ Issue 27/July 07, 2014 Page 7565 threatening complication that results in airway obstruction.1,8 Mechanism of injury to the nerve
includes complete or partial transaction, traction, contusion, crush injury, thermal injury, misplaced ligature or compromised blood supply.8
Total thyroidectomy is the treatment of choice in surgery for papillary carcinoma of thyroid and it involves higher risk of complications.2 Total thyroidectomy was associated with a significantly
increased risk of recurrent laryngeal nerve injury.7
In this case we observed that both hematoma and recurrent laryngeal nerve injury are causes of airway obstruction, although one after the other, unlike in other documented cases where either of them was the cause of stridor.
Hematoma formation occurred slowly over 24hrs suggested by clot formation, indicating that it was not fresh bleeding. Injury to recurrent laryngeal nerve was not due to surgical manipulation as vocal cord movements were normal in immediate post-operative period. Hoarseness of voice was present just before drop in Spo2, suggesting that the onset of recurrent laryngeal nerve injury was
after 24hrs. So we speculate that the cause for recurrent laryngeal nerve injury was pressure effect or compromised blood supply due to hematoma. But worsening of recurrent laryngeal nerve palsy from hoarseness of voice to stridor post hematoma evacuation indicates possible direct injury during re-exploration.
Thus this case differs from other reported cases of postoperative complications following thyroid surgery in terms of occurrence of both hematoma and recurrent laryngeal nerve injury and also difficulty is identifying the cause of recurrent laryngeal nerve injury.
CONCLUSION: Hematoma formation and recurrent laryngeal nerve injury are major causes of airway
related problems following thyroid surgery. In our case, the stridor was due to both hematoma and recurrent laryngeal nerve injury which required tracheostomy. The suspected causes of recurrent laryngeal nerve palsy are compression by hematoma, compromised blood supply or injury during re-exploration.
REFERENCES:
1. Akin M, Kurukahvecioglu O, Anadol AZ, Yuksel O, Teneri F. Analysis of surgical complications of thyroid diseases: results of a single institute. Bratisl lek Listy 2009; 110(1): 27-30
2. Zakaria HM, Al Awad NA, Al Kreedes AS, Al Mulhim AMA, Al-Sharway MA, Hadi MA, Al SayyahA. Recurrent Laryngeal Nerve Injury in Thyroid Surgery. Oman Medical Journal 2011; 26: 34-38, 3. Mihai R, Randolph GW, Thyroid Surgery, Voice and the Laryngeal Examination- Time for
Increased Awareness and Accurate Evaluation. WOJES 2009; 1 (1): 1-5,
4. Harness JK, Fung L, Thompson NW, Burney RE, McLeod MK. Total Thyroidectomy: Complications and Technique. World J. Surg 1986; 10: 781- 86.
5. Lee HS, Lee BJ, Kim SW, Cha YW, Choi YS, Park YH, Lee KD. Patterns of Post-thyroidectomy Haemorrhage, Clinical and Experimental. Otorhinolaryngology 2009; 2: 72-77
6. Deveci U, Altintoprak F, Kapakli MS, Manukyan MN, Cubuk R, Yener N, Kebudi A. Is the Use of a Drain for Thyroid Surgery Realistic? A Prospective Randomized Interventional Study. Hindawi Publishing Corporation Journal of Thyroid Research 2013; 1: 1155- 60.
DOI: 10.14260/jemds/2014/2936
CASE REPORT
J of Evolution of Med and Dent Sci/ eISSN- 2278-4802, pISSN- 2278-4748/ Vol. 3/ Issue 27/July 07, 2014 Page 7566 8. Dutta H, sinha BK, Baskota DK. Reccurent Laryngeal Nerve Palsy after Thyroid surgery and
Literature Review. NJENTHNS 2011; 2: 27- 28.
AUTHORS:
1. Syed Fazal Mahmood 2. Sampathilla Padmanabha 3. Harish Hegde
4. Santhosh K. Gouroji
PARTICULARS OF CONTRIBUTORS:
1. Post Graduate Resident, Department of Anaesthesia, Yenepoya Medical College, Mangalore, Karnataka. India.
2. Professor and HOD, Department of Anaesthesia, Yenepoya Medical College, Mangalore, Karnataka. India.
3. Professor, Department of Anaesthesia, Yenepoya Medical College, Mangalore, Karnataka. India.
4. Senior Resident, Department of Anaesthesia, Yenepoya Medical College, Mangalore, Karnataka. India.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Syed Fazal Mahmood, No. 541, 20th Main Road,
4th T-Block,
Jayanagar, Banglaore-560041, Karnataka, India.
Email: [email protected]
