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CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 5  |  Page : 423-426  

Anesthetic management of a patient of multinodular goiter with retrosternal extension presenting with obstructive sleep apnea for total thyroidectomy


Department of Anaesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra, India

Date of Web Publication5-Sep-2018

Correspondence Address:
Vidhu Bhatnagar
Department of Anaesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_210_17

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  Abstract 


Multinodular goiter (MNG), one of the disorders of the thyroid gland, is often detected as a mass in the neck, but sometimes produces pressure symptoms. We present successful anesthetic management of a case of an obese woman having MNG with retrosternal extension, in the setting of severe OSA, planned for total thyroidectomy. The complicated presentation of the disorder, with challenging airway management during the peri-operative period and a positive outcome is a reason for sharing this experience.

Keywords: Apnea, bronchoscopes, continuous positive airway pressure, goiter, noninvasive ventilation, obesity, substernal


How to cite this article:
Bhatnagar V, Karmarkar AA, S. Raghuvanshi VP. Anesthetic management of a patient of multinodular goiter with retrosternal extension presenting with obstructive sleep apnea for total thyroidectomy. Med J DY Patil Vidyapeeth 2018;11:423-6

How to cite this URL:
Bhatnagar V, Karmarkar AA, S. Raghuvanshi VP. Anesthetic management of a patient of multinodular goiter with retrosternal extension presenting with obstructive sleep apnea for total thyroidectomy. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Nov 30];11:423-6. Available from: https://www.mjdrdypv.org/text.asp?2018/11/5/423/240375




  Introduction Top


Multinodular goiter (MNG) is one of the common disorders of the thyroid gland in endemic goiter areas often presents with the nodular presentation of thyroid substance, as a result of genetic heterogeneity of follicular cells. Although clinical features of MNG vary, direct compression on airway and major vessels requires definitive surgical intervention.[1] A retrosternal extension of this pathological entity leads to greater problems. Obstructive sleep apnea (OSA) is a potential sleep disorder of breathing, correlates positively with obesity and age. It poses greater challenges for anesthesiologists due to difficult mask ventilation, difficult laryngoscopic intubation, accelerated arterial desaturation, apnea-hypopnea during the postoperative period and thus the requirement of postoperative monitoring and delayed discharge status.[2] Any goiter that spreads into the anterior mediastinum (more than 2cm) or drops below the thoracic inlet plane is considered retrosternal.[3] Although surgical management of multinodular goiter requires total thyroidectomy, co-occurrence of retrosternal extension requiring curative sternotomy increases the chances of complications and perioperative morbidity.

Obstructive sleep apnea (OSA) is a syndrome characterized by periodic obstruction of the upper airway during sleep, which could be partial or complete. It occurs when the negative airway pressure during inspiration is more than the oropharyngeal muscles tone, thus causing the airway collapse. OSA has a positive association with increased age and positive family history and frequently occurs in obese patients.[4] We present the anesthetic management of an obese patient who was under treatment for OSA and later detected to have MNG with retrosternal extension.


  Case Report Top


A 59-year-old female patient, weight 85 kg, height 1.52 m body mass index 36.8 kg/m 2), known case of OSA, on regular noninvasive ventilation bilevel positive airway pressure (BiPAP) mode for 4 to 6 h during sleep) presented with worsening of symptoms [Figure 1]. During her evaluation, she was diagnosed to have MNG with retrosternal extension in euthyroid state. The patient had a short neck, neck circumference of 48 cm, clinically no obvious swelling in the neck. The patient had difficulty in lying down supine and had history of breathlessness on lying down flat and preferred sleeping in semi-recumbent position. On preanesthetic examination preanaesthetic clinic, her heart rate (HR) was 98/min, noninvasive blood pressures (NIBP) were 156/92 mm of Hg, room air saturation was 94%, and neck extension was compromised, and flexion was severely restricted. On airway examination, she was Mallampatti class III, mouth opening was 2.5 cm, thyromental distance was only 3.5 cm, with the presence of extensive submental tissue. The thyroid gland was palpable, but the lower extent of the swelling could not be demarcated, the swelling did not move with deglutition. Pemberton's sign was negative. Indirect laryngoscopy revealed normal vocal cord mobility. Free T3, T4, and thyroid-stimulating hormone levels were within normal limits (WNL). Computed tomography (CT) scan revealed large exophytic well-defined heterogeneously enhancing nodule arising from the lower pole of the right lobe of the thyroid gland with retrosternal extension measuring 5.83 cm × 5.22 cm in maximum dimensions and 7.55 cm in superoinferior extent, with a dystrophic calcific focus in its lower portion, causing severe lateral compression of trachea with minimum diameter of 0.38 cm at the site of compression with deviation toward the left [Figure 2]. Polysomnography of the patient revealed apnea-hypopnea Index of 77.3 without continuous positive airway pressure (CPAP) [Figure 3]. Basal arterial blood gases (ABG) at room air revealed a partial pressure of carbon dioxide of 44 mm of Hg.
Figure 1: A 59-year-old obese lady with body mass index of 36.d kg/m2 with multinodular goiter and retrosternal extension showing short neck with no appreciable swelling on visual inspection. Her neck circumference was 48 cm

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Figure 2: Computed tomography scan revealed large exophytic well-defined heterogeneously enhancing nodule arising from the lower pole of the right lobe of the thyroid gland with retrosternal extension measuring 5.83 cm × 5.22 cm in max dimensions and 7.55 cm in superoinferior extent, with a dystrophic calcific focus in its lower portion, causing severe lateral compression of trachea with minimum diameter of 0.38 cm at the site of compression with deviation towards the left

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Figure 3: Polysomnography of the patient revealing Apnea-hypopnea Index of 77.3 without continuous positive airway pressure

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The patient was accepted in the American Society of Anaesthesiologist grading III and an informed consent, specifying postoperative ventilation and prolonged stay in Intensive Care Unit (ICU) was taken. The patient was also counseled for awake flexible fiberoptic bronchoscopy-assisted intubation and consent for the same taken.

No preoperative sedation was given, and the standard monitors for HR, NIBP, electrocardiography, pulse oximetry were attached in the operating room, baseline vitals were recorded. The patient was prepared for awake flexible fiberoptic bronchoscopic-assisted intubation (FOB) in semi-recumbent position under nebulization, pharyngeal spray of lignocaine. Laryngeal blocks could not be given due to the distorted anatomy and spray as you go technique was uitlized for FOB. A total dose of 250 mg of lignocaine was utilized. The patient was premedicated with 0.2 mG of glycopyrrolate intravenously. Endotracheal intubation was performed nasally using 7-sized flexo-metallic endotracheal tube, followed by induction with propofol (1.5 mG/Kg) and muscle relaxation with vecuronium (0.05 mG/Kg). Anesthesia was maintained on oxygen, air, and desflurane. As a part of multimodal analgesia, patient was given fentanyl (0.5 mcg/Kg) and paracetamol (15 mG/Kg) postintubation.

Total thyroidectomy was performed and the retrosternal part was removed by cervical approach. Around 5.5 cm × 5.0 cm retrosternal thyroid tissue was removed [Figure 4]. Post induction and preextubation ABGs were WNL. The perioperative fluid was tightly balanced. The entire perioperative period was uneventful. At the end of surgery, the patient was given reversal, leak test (after deflating endotracheal tube cuff) was performed, and mobility of vocal cords was assessed by laryngeal ultrasound. The patient was extubated awake in semirecumbant position and bridging with noninvasive ventilation Bipap mode in ICU for 4 h was given for complete recovery. The patient was closely monitored, and intermittent CPAP support for 24 h was prescribed.
Figure 4: Multinodular goiter with retrosternal extension

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  Discussion Top


Terms such as retrosternal, substernal, intrathoracic, or mediastinal have been used to describe a goiter that extends beyond the thoracic inlet though there is a lack of consensus regarding the exact definition of a retrosternal goiter (RSG).[5] Several definitions have been proposed to clarify the meaning of a RSG, some of which include a goiter: (i) that descends below the plane of the thoracic inlet (ii) with more than 50% of the mass lying below the plane of the thoracic inlet (iii) with major intrathoracic extension requiring reaching into the mediastinum for dissection (iv) growing into the anterior-superior mediastinum to a depth of >2 cm [5] or (v) reaching the level of the fourth thoracic vertebra.[6] The majority of patients present with shortness of breath (68.8%). This was misleading in our patient and the breathlessness could either be entirely due to or co-occurrence with OSA. Other modes of presentation include neck mass (75%), hoarseness of voice (37.5%), dysphagia (31.3%), stridor/wheezing (19%), or superior vena cava obstruction. Upper airway obstruction due to thyroid gland has been reported up to 31%,[2] and difficulty in intubation has been reported in 11%.[7],[8]

The overall incidence of difficult intubation in thyroid surgery has been reported by Amathieu et al. as 11.1%.[7] FOB has been used as a successful tool in difficult airway due to thyroid swellings.[8],[9] Central airway obstruction produces symptoms of dyspnea, stridor, or obstructive pneumonia and is often misdiagnosed with asthma.[8] In a recent publication, the CT scan was considered the gold-standard preoperative radiological investigation, and in our case too CT scan gave an accurate estimate.[10]

In most cases, suppressive therapy with thyroxine is ineffective in reducing the size of MNGs; radio-iodine therapy is both generally ineffective in large goiters and may induce acute inflammation and swelling of the gland with the potential for airway obstruction. Surgery is the only effective treatment for RSGs. Only around 2% of patients undergoing thyroidectomy for RSG will require surgical access other than a standard collar incision (either manubriotomy, sternotomy, or thoracotomy).[9] The operation of choice is total thyroidectomy, eliminating the need for potential secondary surgery due to regrowth of retained thyroid tissue.

Thyrotoxic features are reported in <10% of RSG cases. Prospective studies document the incidence of carcinoma development in goiters at 1.3–3.7 new cases/1000 patients. However, a recent review of the evidence-based management of sub-sternal goiters concluded that the incidence of malignant transformation is equivalent in RSGs to those residing entirely in the neck.[9] Anesthesia management is demanding and requires careful planning of complex airway management owing to OSA and possible recurrent laryngeal nerve paresis/palsy perioperatively.[11] While we managed our case by awake fiberoptic intubation, newer ways of airway management are also promising such as video laryngoscope-assisted intubation in supine or lateral position.[12]

The limitations for the use of video laryngoscope are its learning curve and also its availability. Moreover, trying to secure airway with video laryngoscopes may be difficult in semi-recumbent or sitting position (as was required in our case); though securing the airway in lateral position using video laryngoscopes is possible. Although further studies are required for a considerable statistical significance of such maneuvers.


  Conclusion Top


Despite all the advances in investigative modalities, RSG still exists in 20% of patients over 70 years in endemic regions. RSG may be a cause of OSA which itself is responsible for difficult airway management. Thorough preoperative airway evaluation, patient preparation, readiness for airway management by flexible fiberoptic bronchoscopy or invasively if needed, and closed perioperative and postoperative monitoring hold the key for successful outcomes. The practiced technique is the best technique when managing a difficult airway.

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.

Acknowledgment

Our acknowledgment to the Oncosurgery team of our hospital, consisting of Dr Naresh Saida and his post graduate residents.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Winbladh A, Järhult J. Fate of the non-operated, non-toxic goitre in a defined population. Br J Surg 2008;95:338-43.  Back to cited text no. 1
    
2.
Hwang D, Shakir N, Limann B, Sison C, Kalra S, Shulman L, et al. Association of sleep-disordered breathing with postoperative complications. Chest 2008;133:1128-34.  Back to cited text no. 2
    
3.
Shaha AR. Substernal goiter: What is in a definition? Surgery 2010;147:239-40.  Back to cited text no. 3
    
4.
Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA 2004;291:2013-6.  Back to cited text no. 4
    
5.
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. 5
    
6.
Candela G, Varriale S, Di Libero L, Manetta F, Giordano M, Maschio A, et al. Surgical therapy of goiter plunged in the mediastinum. Considerations regarding our experience with 165 patients. Chir Ital 2007;59:843-51.  Back to cited text no. 6
    
7.
Amathieu R, Smail N, Catineau J, Poloujadoff MP, Samii K, Adnet F, et al. Difficult intubation in thyroid surgery: Myth or reality? Anesth Analg 2006;103:965-8.  Back to cited text no. 7
    
8.
Hedayati N, McHenry CR. The clinical presentation and operative management of nodular and diffuse substernal thyroid disease. Am Surg 2002;68:245-51.  Back to cited text no. 8
    
9.
White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg 2008;32:1285-300.  Back to cited text no. 9
    
10.
Grainger J, Saravanappa N, D'Souza A, Wilcock D, Wilson PS. The surgical approach to retrosternal goiters: The role of computerized tomography. Otolaryngol Head Neck Surg 2005;132:849-51.  Back to cited text no. 10
    
11.
Chakera A, van Heerden PV, van der Schaaf A. Elective awake intubation in a patient with massive multinodular goitre presenting for radioiodine treatment. Anaesth Intensive Care 2002;30:236-9.  Back to cited text no. 11
    
12.
Dwivedi D, Bhatnagar V, Tandon U, Kumar P. Airway management with videolaryngoscope in a morbidly obese patient in a tertiary care centre: Are the peripheral hospitals ready for such a scenario? Anesth Essays Res 2017;11:533-4.  Back to cited text no. 12
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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