ANAESTHESIA FOR A HUGE MULTINODULAR GOITER

Print This Article

A 76 years old male was scheduled to undergo total thyroidectomy for a huge multinodular goiter.

Patient presented with a huge swelling in front of the neck, which increased in size gradually over the years

Compression symptoms were present – patient had difficulty in breathing in lying flat, was comfortable in left lateral position and hoarseness of voice was present

Patient’s medical history includes morbid obesity, diabetes, hypertensive, hypothyroidism, coronary artery disease (s/p ptca to rca in 2015) with moderate lv dysfunction, obstructive sleep apnea on overnight bipap support

ANAESTHESIA FOR A HUGE MULTIGOIDULAR GOITER

PRE-OPERATIVE PLANNING

Routine investigations, echocardiography, cardiologist opinion, pulmonologist opinion, Ent surgeon opinion were taken
Blood investigation were within normal limits expect haemoglobin of 7.8g
Echo showed regional wall motion abnormality with ejection fraction of 35% and presence mild pulmonary artery hypertension
Patient was antiplatelet Tab clopilet 75mg regularly, cardio opinion was sought, clopilet was asked to stop 5 days prior to surgery and was planned to bridge with low molecular weight heparin and the same was stopped 12 hrs before surgery
Pulmonologist opinion was sought, added steroids and nebulisations and asked to continue cpap support pre operatively
Flexible laryngoscope done by Ent surgeon showed – Bulging lateral pharyngeal wall on right side pushing entire larynx to medially B/L vocal cords mobile, airway narrowing present +

AIRWAY ACESSSMENT:

Patient had double chin with huge thyroid swelling in the neck
Mouth opening was more than 3 finger breaths
Mallampati class 4 (only hard palate was visible)
Terminal neck extension restricted

OPTIMISATION AND PREPARATION

Antiplatelet was stopped and bridged with low molecular weight heparin, diuretics were given and fluid restriction were followed strictly
Cpap support continued along with nebulisation and steroids
One-unit prbc transfused day before the surgery
Awake fibrotic intubation planned and same was informed and counselled to the patient
NIL PER ORAL 6 hours for solid foods and 2 hours for liquid were explained clearly
Informed and high-risk consent with regards to airway, need for tracheostomy and multiple comorbidities was explained and consent obtained from patient and attenders
Nasal decongestion drops were given night before the surgery and also on the day of surgery

AWAKE FIBROPTIC INTUBATION AND INTRA OPERATIVE

Nebulisation with inj hydrocort 50mg + 2% lignocaine given 15 minutes before procedure in recovery room
Inj glycopyrrolate 0.2mg given iv at same time to decrease the secretions
Airway block * superior laryngeal nerve block and intratracheal injection of 4% lignocaine given
Awake fob done in patients comfortable position (i.e left lateral ) , with difficulty entered trachea and carina identified, 7mm ID fm tube inserted and connected to ventilator
After the presence of continuous end tidal c02 wave forms, the patient was sedated with propofol (2mg/kg) and paralysed with cis-artacurium 0.15mg/kg
Arterial line secured in the left radial artery for continuous hemodynamic monitoring
Remi fentanyl infusion was started at 150 mcg/hour
Intra operative period was uneventful, duration of 2hours blood loos of 150ml with good urine output
Intra op findings include the presence of embryological remnants of thyroid gland in retro sternal region

POST OPERATIVE PERIOD

Initially planned for post op elective ventilation given difficulty with the airway
Surgeons deferred tracheostomy with intraoperative finding of trachea being spared and normal (no evidence of tracheomalacia and narrowing)
After reversing neuromuscular relaxation, video laryngoscopy was done, b/L vocal cords visualized
The patient was extubated after good spontaneous respiratory efforts, post post-extubation patient maintained his airway
Shifted to the intensive care unit for post-operative observation and management
On reviewing patient on post operative day one , patient was comfortable on supine position , vocalising well and orals were well tolerated
His cpap support was continued and antiplatelets were restated after cardiologist review
Shifted to ward on post op day 1 evening and was discharged on post op day 3

DISCUSSION

Tracheal intubation is a fundamental technique in the administration of general anaesthesia. However, it is associated with several complications, including tissue trauma, particularly in cases of difficult intubation. According to the literature, thyroid surgery is considered a risk factor for difficult intubation, often due to the presence of a large goiter or malignancy. The reported incidence of difficult intubation during thyroid procedures ranges from 5.3% to 24.6%, which is higher than in the general population. A thorough and meticulous preoperative evaluation of the upper airway can help anticipate intubation challenges and alert anaesthesiologists to the risk of dental injuries.

Thyroid surgery is a frequently performed procedure in the field of head and neck surgery and is typically conducted under general anaesthesia. The incidence of difficult tracheal intubation (DTI) in these cases is approximately 10% (1). Due to the thyroid gland’s close anatomical proximity to the larynx, laryngopharynx, and trachea, large or invasive thyroid masses can obstruct the airway, increasing the risk of anaesthesia-related complications, including morbidity and mortality. Preoperative assessment of airway anatomy and pathological changes is crucial to facilitate safe airway management. Nonetheless, many cases of difficult intubation in thyroid surgery remain unpredictable due to the limitations of current predictive tools.