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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 22  |  Issue : 1  |  Page : 32-35

Elective short-term nasotracheal intubation for postthyroidectomy tracheomalacia due to a long-standing large goiter: An experience at tertiary care center


Department of Otorhinolaryngology and Head and Neck Surgery, Safdarjung Hospital, New Delhi, India

Date of Submission13-Oct-2019
Date of Decision15-Oct-2019
Date of Acceptance18-Dec-2019
Date of Web Publication01-Jun-2020

Correspondence Address:
Dr. Rohit Bhardwaj
SB-201, 10B, Transit Flats, Hudco Place, Andrews Ganj, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJOH.SJOH_15_19

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  Abstract 


Long-standing large goiters impose possibility of various complications. Tracheomalacia is one such feared problem. The presence of bilateral mobile vocal folds and extubation failure after surgery affirms diagnosis. Methods to deal with tracheomalacia include silicon tracheal stent grafts, tracheostomy, and prolonged intubation. We share our experience of the successful management of tracheomalacia with elective short-term endotracheal intubation. A 36-year-old female presented with a massive neck swelling, for the past 9 years along with slight change in voice and breathing difficulty. We performed near total thyroidectomy for colloid goiter. Intra-operative assessment suggested tracheomalacia. We kept patient on nasotracheal intubation for 1 week, and then extubated successfully. Postthyroidectomy tracheomalacia is a rare but significant complication. We advocate trial of our successful method of elective short-term intubation for its management. This can prove an easy and cost-effective alternative in comparison with tracheostomy or tracheal stent grafts.

Keywords: Extubation, large goiter, tracheal stent grafts, tracheomalacia, tracheostomy


How to cite this article:
Chauhan V, Tuli IP, Bhardwaj R, Gupta A, Ponnusamy S. Elective short-term nasotracheal intubation for postthyroidectomy tracheomalacia due to a long-standing large goiter: An experience at tertiary care center. Saudi J Otorhinolaryngol Head Neck Surg 2020;22:32-5

How to cite this URL:
Chauhan V, Tuli IP, Bhardwaj R, Gupta A, Ponnusamy S. Elective short-term nasotracheal intubation for postthyroidectomy tracheomalacia due to a long-standing large goiter: An experience at tertiary care center. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2020 Oct 31];22:32-5. Available from: https://www.sjohns.org/text.asp?2020/22/1/32/285551




  Introduction Top


Large long-standing goiters are notorious for posing significant difficulties to surgeons, both intraoperatively and postoperatively. Preserving bilateral recurrent laryngeal nerves and parathyroid glands in dealing with large benign goiters has always been a tedious task. Tracheomalacia is also one such feared complication. It is defined as reduction in the cross-sectional area of trachea to less than half of its normal. Besides being idiopathic in certain situations, tracheomalacia can also be caused by surgical procedures, trauma, mechanical changes, or chronic inflammation.[1],[2] Long-standing large goiters can cause tracheomalacia by means of continuous extrinsic mechanical compression. This leads to the loss of rigidity in the cartilaginous framework, ultimately resulting in dynamic airway collapse of >50% of the normal tracheal diameter.[3] The reported incidence of tracheomalacia ranges between 0% and 10%.[4] Paradoxically, removal of such a compressive large goiter might results in life-threatening airway collapse, which mandates urgent intervention to stabilize the airway.[3]

Possible risk factors associated with tracheomalacia include preoperative history of stridor, radiological evidence of tracheal deviation or compression, retrosternal goiter, and difficulty in intubation. Fluoroscopy had been used to diagnose tracheomalacia but had certain limitations like difficulty visualizing the airway in obese individuals and a tendency to underestimate the degree of collapse.[5] Multidetector computed tomography (CT) scans with higher quality multiplanar reformation and three-dimensional reconstruction images have improved diagnostics for tracheomalacia. Dynamic magnetic resonance imaging (MRI) has further added in diagnosing increased collapsibility of the airway in tracheomalacia.[6] Tracheobronchoscopic visualization can be taken as “gold standard” method for diagnosing tracheomalacia.

Intra-operative assessment showing soft and floppy trachea on palpation, absence of peritubal leak on deflation of endotracheal tube cuff, obstruction to spontaneous respiration during gradual withdrawal of the endotracheal tube and falling hemoglobin oxygen saturation (SpO2) on pulse oximetry suggest the possibility of tracheomalacia.[7] In our case also we diagnose the tracheomalacia based on preoperative CT findings of tracheal deviation and luminal narrowing, surgeon's intraoperative assessment supplemented by anesthetist's opinion. The patient was managed successfully by elective short-term nasotracheal intubation for 7 days, and successfully weaned off the endotracheal tube.


  Case Report Top


A 36-year-old female presented to our outpatient department with the primary complain of massive neck swelling, which has been gradually progressing [Figure 1]. Her associated complaints included slight difficulty in breathing and in swallowing. She did not have a change in voice. The swelling was soft in consistency. Position of the trachea could not be ascertained because of swelling. Endoscopic endolaryngeal examination showed bilateral mobile vocal cords with adequate chink. She was clinically euthyroid.
Figure 1: Clinical photograph of patient with neck swelling

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Biochemically, she had normal T3 and T4. Thyroid-stimulating hormone was raised. Serum calcitonin and thyroglobulin levels were also measured in the normal range. Fine-needle aspiration cytology suggested the possibility of Bethesda category II benign lesion (colloid goiter).

CT scan detailed the swelling as gross enlargement of the thyroid gland with heterogeneous enhancement and foci of calcification and cystic changes. The enlarged gland was causing compression of the trachea [Figure 2] and narrowing of oesophagus. It was also having retrosternal extension for about 1.2 cm from the superior border of manubrium [Figure 3]. MRI further confirmed the above-mentioned findings and suggested the possibility of multinodular goiter [Figure 4] and [Figure 5].
Figure 2: Axial computed tomography scan films depicting enlarged thyroid gland (marked by star) and compressed trachea (marked by arrow)

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Figure 3: Sagittal reconstruction computed tomography scan images depicting enlarged thyroid gland with retrosternal extension (marked by star) and compressed trachea (marked by arrow)

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Figure 4: Axial magnetic resonance imaging images depicting enlarged thyroid gland (marked by star) and compressed trachea (marked by arrow)

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Figure 5: Sagittal magnetic resonance imaging images showing enlarged thyroid gland (marked by star) with retrosternal extension and compressed trachea (marked by arrow)

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We performed near-total thyroidectomy under general anesthesia for her. Meticulous dissection carried out to preserve bilateral recurrent laryngeal nerves and parathyroid glands. After removal of the gland, excised thyroid gland specimen which measured 18 cm (vertically) × 16 cm (horizontally) × 12 cm (anteroposteriorly) and weighed 810 g [Figure 6]. On intraoperative assessment, we found the trachea to be very much pliable. We conveyed the possibility of dealing with tracheomalacia to anesthetists as they might have difficulties during extubation. They confirmed the possibility by seeing absent peritubal air leak after deflating the cuff around the endotracheal tube and also by noticing increasing airway pressure on gradual withdrawal of the endotracheal tube.
Figure 6: Excised thyroid gland specimen which measured 18 cm (vertically) ×16 cm (horizontally) ×12 cm (anteroposteriorly) and weighed 810 g

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After confirming the diagnosis of tracheomalacia with all these evidences, we kept the patient on awake nasotracheal intubation. The extubation was attempted in operation theater after 7 days, and it was uneventful. She was kept under observation for 2 days and then discharged. She has been under our follow for almost 1 year and is free of any respiratory complaint.


  Discussion Top


Since definite treatment guidelines are not available for tracheomalacia. Considering the varied etiology, various options have been suggested to deal with this. These ranges from noninvasive conservative management (observation alone in milder case, continuous positive airway pressure [CPAP] as pneumatic stent) to invasive modalities (tracheoplasty, endotracheal stenting, tracheostomy).

The treatment of respiratory tract infections, smoking cessation, and relaxation exercises have been useful for patient developing tracheomalacia as a result of chronic obstructive pulmonary disease.[8] Milder case of developing tracheomalacia can be addressed by the use of nonsteroidal anti-inflammatory drugs and corticosteroids.[9] CPAP by working as pneumatic stent has also been shown as an effective adjunctive therapy for tracheobroncomalacia.[10],[11]

Airway stents are another promising option for dealing with tracheomalacia. They have shown to improve the rigidity of the malacic segment if placed accurately. Silicon stents are the most commonly used stents.[12] Mastering the art of stent placement has a learning curve. Due to the dynamic nature of tracheomalacia, the ongoing continuous changes in airway size and shape predispose the stents to displacement and/or fracture.

Tracheoplasty has also been proven effective in dealing with tracheomalacia. It can utilize autologous grafts as well as prosthetics to reshape and strengthen the airway wall.[13] These are less cost effective, needs a long learning curve.

Tracheostomy has also been considered as an option for treatment of tracheomalacia. It can help by either stenting or bypassing the malacic segment. Tracheostomy, Apart from being an invasive procedure, it lacks patient compliance and also harbors the risk of tracheal stenosis. All these restrict its use. However, it is the only available option in some selected cases.

The utility of endotracheal tubes as a stent postoperatively has been described successfully in studies.[14] We recommend elective short-term nasotracheal intubation to deal with cases of tracheomalacia, once the causative factor of sustained prolong mechanical pressure as benign thyroid diseases, has been removed. It helps in strengthening the malacic tracheal segment. The malacic tracheal segment is taken up by fibrous scarring during healing. There are no significant complications. It is safe as well as cost-effective method for dealing with tracheomalacia. Our study has the limitation of being a single case report, but it opens doors to research in this particular direction.

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.
Nuutinen J. Acquired tracheobronchomalacia. Eur J Respir Dis 1982;63:380-7.  Back to cited text no. 1
    
2.
Jokinen K, Palva T, Nuutinen J. Chronic bronchitis. A bronchologic evaluation. ORL J Otorhinolaryngol Relat Spec 1976;38:178-86.  Back to cited text no. 2
    
3.
Kandaswamy C, Balasubramanian V. Review of adult tracheomalacia and its relationship with chronic obstructive pulmonary disease. Curr Opin Pulm Med 2009;15:113-9.  Back to cited text no. 3
    
4.
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. 4
    
5.
Aquino SL, Shepard JA, Ginns LC, Moore RH, Halpern E, Grillo HC, et al. Acquired tracheomalacia: Detection by expiratory CT scan. J Comput Assist Tomogr 2001;25:394-9.  Back to cited text no. 5
    
6.
Suto Y, Tanabe Y. Evaluation of tracheal collapsibility in patients with tracheomalacia using dynamic MR imaging during coughing. AJR Am J Roentgenol 1998;171:393-4.  Back to cited text no. 6
    
7.
Agarwal A, Mishra AK, Gupta SK, Arshad F, Agarwal A, Tripathi M, et al. High incidence of tracheomalacia in longstanding goiters: Experience from an endemic goiter region. World J Surg 2007;31:832-7.  Back to cited text no. 7
    
8.
Grandevia B. The spirogram of gross expiratory tracheobronchial collapse in emphysema. Q J Med 1963;32:23-31.  Back to cited text no. 8
    
9.
McAdam LP, O'Hanlan MA, Bluestone R, Pearson CM. Relapsing polychondritis: Prospective study of 23 patients and a review of the literature. Medicine (Baltimore) 1976;55:193-215.  Back to cited text no. 9
    
10.
Ferguson GT, Benoist J. Nasal continuous positive airway pressure in the treatment of tracheobronchomalacia. Am Rev Respir Dis 1993;147:457-61.  Back to cited text no. 10
    
11.
Kanter RK, Pollack MM, Wright WW, Grundfast KM. Treatment of severe tracheobronchomalacia with continuous positive airway pressure (CPAP). Anesthesiology 1982;57:54-6.  Back to cited text no. 11
    
12.
Dumon J, Cavaliere S, Diaz-Jimenez J, Vergnon J. Seven-year experience with the Dumon prosthesis. J Bronchol 1996;3:6-10.  Back to cited text no. 12
    
13.
Hanawa T, Ikeda S, Funatsu T, Matsubara Y, Hatakenaka R, Mitsuoka A, et al. Development of a new surgical procedure for repairing tracheobronchomalacia. J Thorac Cardiovasc Surg 1990;100:587-94.  Back to cited text no. 13
    
14.
Singh B, Lucente FE, Shaha AR. Substernal goiter: A clinical review. Am J Otolaryngol 1994;15:409-16.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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