Airway Complications and Management after Thyroidectomy

1
Airway Complications and Management after
Thyroidectomy
UT AnesthesiologyGrand RoundsMarch 31st 2005

• Jose M. Soliz, M.D.
• Christiane Vogt-Harenkamp, M.D.

2
Case History

• 19 year old Hispanic female presents for a
  left hemithyroidectomy. The patient underwent a
  right hemithyroidectomy six weeks previously for
  a thyroid nodule. On final pathology report, the
  patient was noted to have papillary thyroid
  cancer.

3
Case History

• Medications none
• Allergies none
• Past medical history none
• Past surgical history right hemithyroidectomy
  six weeks prior. uneventful, no noted
  complications

4
Case History

• Family History non-contributory
• Social History denies etoh, smoking, drugs
• ROS on day of surgery, patient denied any
  fever, rhinorrea, hoarseness, or sore throat.
  Does complain of three day history of non
  productive cough without fever which had about
  resolved on day of surgery.

5
Physical Exam

• General thin, 55kg
• Airway Mallampati Class I, gt3 FBMO, gt5cm TM
  distance, good neck extension and flexion
• CV RRR, no murmurs rubs or gallops
• Respiratory clear to auscultation
• Extremities WNL

6
Perioperative Course

• Pre-induction Versed, prophylactic antibiotic
• Induction Propofol, Fentanyl, Lidocaine,
  Rocuronium
• Intubation Grade I view, 7.0 armored ETT placed
  with cuff inflated, non traumatic, 1 attempt
• Surgical course uneventful, minimal blood loss
• Extubation patient had four twitches, reversed,
  spontaneously breathing, positive hand grasp, eye
  opening on command

7
Extubation

• Cuff deflated, tube pulled. Patient began
  breathing low tidal volumes with audible stridor.
  

Differential Diagnosis? What to do next?
8
Post-Extubation

• Patient desaturates to high 80s low 90s.
  Positive pressure applied with jaw lift. Assisted
  ventilation possible with movement of adequate
  tidal volumes. O2 sats return to 100. Patient
  is then able to spontaneously move adequate tidal
  volumes with continued audible stridor and jaw
  lift.

9
Post-Extubation

• Decision was made to deepen patient with
  sevoflurane while maintaining spontaneous
  ventilation.
• DL performed by anesthesiology team and surgical
  attending.
• Both vocal cords in paramedian position with no
  movement of Right vocal cord, and minimal
  movement of Left vocal cord with passive
  expiration, laryngeal and cord edema noted.
• Surgeon sprays vocal cords and larynx with
  racemic epinephrine. Stridor continues.
• ENT consulted intraoperatively, noted the above
  findings

10
Post-Extubation Plan

• Plan re-intubate patient with smaller diameter
  tube 6.0, start high dose steroids. Transport
  patient intubated and sedated to ICU
• Plan for three days of high dose steroids
• Trial of extubation and DL in OR, with ENT
  present for examination and possible
  tracheostomy.
• Three days later, after EUA by ENT, findings of
  laryngeal edema had resolved, but right true
  vocal cord paralysis, and left true vocal cord
  paresis were unchanged and surgical airway was
  performed
• Patient later discharged home with tracheostomy,
  was decannulated 2.5 months later with return of
  adequate cord function

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Airway Complications and Management after
Thyroidectomy

• Outline

• Anatomy
• Complications and management
• Intubation related and post-op
  complications
• Diagnosis and prevention
• Therapeutic measures
• Take home message
• Focus on laryngeal nerve palsies

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• Anatomy

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Airway Complications and Management after
Thyroidectomy

• Anatomy of the Larynx

• Begins at base of tongue, ends at beginning of
  trachea
• Anterior to esophagus, extends from C5 to C6
  (adults) and C3 to C4 in children
• Houses vocal cords voice generation they extend
  from arytenoid cartilages posteriorly to thyroid
  cartilage anteriorly
• Functions as valve open during respiration, half
  open and modulated during phonation, closed
  during swallowing and before coughing

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Airway Complications and Management after
Thyroidectomy

• Anatomy of the Larynx

• Consists of 9 cartilages (thyroid frontal,
  cricoid complete ring, epiglottis, arytenoids,
  cuneiformes, corniculates) and
• 4 joints plus fibro-elastic membranes, muscles
  and mucous membranes
• Connects and separates oral cavity with / from
  airway / esophagus respectively
• superior laryngeal artery as branch of sup.
  thyroid artery from external carotid artery
  inferior laryngeal artery from thyro-cervical
  trunk and subclavian artery

15

• Topographic Anatomy of Larynx and Trachea

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Airway Complications and Management after
Thyroidectomy

• Innervation of the Larynx

• Above vocal cords superior laryngeal nerve (CN
  X)
• internal branch for sensory innervation of
  supra-glottic mucosa,
• external branch with motor fibers to cricothyroid
  muscle
• Below vocal cords recurrent laryngeal nerve
• motor innervation of intrinsic laryngeal muscles
  (abductors) ,
• sensory innervation of mucosa below vocal cords

17

• Innervation

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19
Airway Complications and Management after
Thyroidectomy

• Intubation related complications
• Tracheal tear
• arytenoid subluxation (from placement of tube)
  can phonate, difficulty breathing
• posterior lateral dislocation of arytenoids (from
  tube removal) can cause hoarseness, but good air
  movement
• laryngeal edema
• laryngeal nerve apraxias (can occur by
  compression of anterior ramus of RLN by ETT cuff.
  May lead to temporary unil. or bil RLN palsy
• long term intubation tracheomalacia, scarring,
  granuloma

20
Airway Complications and Management after
Thyroidectomy

• Incidence of respiratory complications at
  extubation and in the recovery room is greater
  than at intubation
• Hematoma (0.79 -1.2) ? airway obstruction
• Laryngeal edema (0.19) ? airway obstruction
• Hypoparathyroidism, temp. 0.9-8.3, perm. lt1.7
  ? stridor, hypocalcemia
• Dysphagia (1.4)
• Infection (0.3)
• Tracheomalacia
• (Rosato L. et al. World J Surg. 2004
  Mar28(3)271-6.
• Hermann M. et al. Ann Surg. 2002
  Feb235(2)261-8
• Kark AE. et al Br Med J (Clin Res Ed) 1984 Nov
  24289(6456)1412-5)

21
Airway Complications and Management after
Thyroidectomy

• Unilateral recurrent laryngeal nerve palsy,
• temp. 0.2 - 7, 50-93 of cases,
• perm.(after 6-24 months) 0.2 -1.6
• of note 1.9 of patients without and 3 of
  patients presenting with carcinoma of the thyroid
  have unilateral/ ipsilateral recurrent laryngeal
  nerve palsy pre-operatively) ? hoarseness,
  impaired coughing, aspiration 30-50 without
  symptoms!
• (Rosato L. et al. World J Surg. 2004
  Mar28(3)271-6.
• Hermann M. et al. Ann Surg. 2002
  Feb235(2)261-8
• Kark AE. et al Br Med J (Clin Res Ed) 1984 Nov
  24289(6456)1412-5)

22
Airway Complications and Management after
Thyroidectomy Recurrent laryngeal nerve palsy
- Unilateral

• Symptoms
• hoarseness
• breathlessness
• ineffective cough
• aspiration
• glottic incompetence

Farling, P.A. Thyroid Surgery. British Journal
of Anaesthesia, 2000, Vol. 85, No.1, 15-28
23
Airway Complications and Management after
Thyroidectomy

• Bilateral recurrent laryngeal nerve palsy (0.4
  -1.9) ? airway obstruction
• Damage to the superior laryngeal nerve (3.7-25)
  ? voice alteration
• (Rosato L. et al. World J Surg. 2004
  Mar28(3)271-6.
• Hermann M. et al. Ann Surg. 2002
  Feb235(2)261-8
• Kark AE. et al Br Med J (Clin Res Ed) 1984 Nov
  24289(6456)1412-5)

24
Airway Complications and Management after
Thyroidectomy Recurrent laryngeal nerve palsy

• Injury can occur by a number of mechanisms such
  as ischemia, contusion, entrapment, and actual
  transection
• Higher risk of damage for malignancy and
  secondary operations
• Anatomic variability and distortions will
  increase the risk of nerve injury

Farling, P.A. Thyroid Surgery. British Journal
of Anaesthesia, 2000, Vol. 85, No.1, 15-28
25
Airway Complications and Management after
Thyroidectomy

• RISKFACTORS FOR RECURRENT LARYNGEAL NERVE DAMAGE
• No or incomplete dissection and exposure of
  recurrent laryngeal nerve (Visualization required
  along the distance between branching of inferior
  thyroid artery and entry of nerve into
  cricothyroid cartilage)
• Non- recurrent laryngeal nerve (anatomical
  variation, 0.25-0.79, only on right side)
• Thyroid cancer
• Total thyroidectomy (permanent nerve damage)
• Re-do surgery (recurrence or cancer)
• Sub-sternal goiter
• Ligature of the inferior laryngeal artery
• (Friedrich T. et al Zentralbl Chir.
  2000125(2)137-143
• Defechereux T. et al Acta Chir Belg.2000
  Mar-Apr100(2)62-67)

26
Airway Complications and Management after
Thyroidectomy

• RISKFACTORS FOR RECURRENT LARYNGEAL NERVE DAMAGE
• The risk of recurrent laryngeal nerve palsy
  with total thyroidectomy for cancer or in re-do
  surgery for recurrence of goiter is about 10
  times higher than for one-time surgery in benign
  disease.
• (Friedrich T. et al Zentralbl Chir.
  2000125(2)137-143
• Defechereux T. et al Acta Chir Belg.2000
  Mar-Apr100(2)62-67)

27
Airway Complications and Management after
Thyroidectomy

• Prevention
• Pre-operative laryngoscopy
• 1.9 of patients without and 3 of patients
  presenting with carcinoma of the thyroid have
  unilateral/ ipsilateral recurrent laryngeal nerve
  palsy pre-operatively
• Complete dissection and exploration of recurrent
  laryngeal nerve during surgery
• visualization required along the distance between
  branching of inferior thyroid artery and entry of
  nerve into cricothyroid cartilage)
• Awareness of anatomical variations

28
Airway Complications and Management after
Thyroidectomy

• Prevention
• Continuous RLN monitoring may be useful in
  certain cases, but time consuming, requires
  spontaneous ventilation, and incidence of false
  negatives. Also controlled trials have shown no
  statistical reduction in paralysis, paresis, or
  total injury rates to the RLN
• May perform deep extubation with spontaneous
  breathing to observe vocal cord movement.

• Farling, P.A. Thyroid Surgery. British Journal
  of Anaesthesia, 2000, Vol. 85, No.1, 15-28
• Robertson ML, Steward DL, Gluckman JL, et al.
  Continuous laryngeal nerve integrity monitoring
  during thyroidectomy does it reduce risk of
  injury? Otolaryngology Head and Neck Surgery.
  2004 Nov 131(5)596-600.

29
Airway Complications and Management after
Thyroidectomy

• Therapeutic strategies for unilateral and
  bilateral recurrent laryngeal nerve palsy
• Unilateral
• spontaneous recovery of function (40)
• logopedic treatment
• electro therapy
• surgical (medialization of vocal cords)
• Joshua B. et al Isr Med Assoc J 2004
  Jun6(6)336-8
• Tanaka S. et al Laryngoscope 2004
  Jun114(6)1118-22
• Cheng SC. Et al Zhonghua Er Bi Yan Hou Ke Za Zhi
  2004 Aug39(8)464-8)

30
Airway Complications and Management after
Thyroidectomy

• Therapeutic strategies for unilateral and
  bilateral recurrent laryngeal nerve palsy
• Bilateral
• Reintubation (if paralyzed in para-median
  position
• Tracheostomy
• Surgical
• endoscopic posterior ventriculocordectomy,
• nerve decompression from ligatures or scar
  tissue, asap!
• glottic widening procedures after 6-9 months
• Joshua B. et al Isr Med Assoc J 2004
  Jun6(6)336-8
• Tanaka S. et al Laryngoscope 2004
  Jun114(6)1118-22
• Cheng SC. Et al Zhonghua Er Bi Yan Hou Ke Za Zhi
  2004 Aug39(8)464-8)

31
Airway Complications and Management after
Thyroidectomy

• Therapy of other Complications (incl. Intubation
  related Damage )
• Hematoma
• immediate reintubation, evacuation, hemostasis
• delayed evacuation, hemostasis, and (awake)
  re-intubation, tracheostomy
• Laryngeal edema
• Reintubation with small ETT, steroids,
  extubation after 24 or 48 hours with leak test
  and over airway exchange catheter
• Scarring
• Laser ablation of arytenoid scar tissue
• Tracheomalacia
• Re-intubation
• surgical correction

32
Airway Complications and Management after
Thyroidectomy

• Therapy of other Complications (incl. Intubation
  related Damage )
• Apraxia of recurrent laryngeal nerve with
  temporary unil. or bil RLN palsy (compression of
  anterior ramus of RLN by ETT cuff)
• Reintubation with smaller tube,
• racemic epinephrine inhalation,
• Tracheostomy
• NOTE measure cuff pressures, or inflate cuff
  only to negative leak

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Take home message

• Identification of recurrent laryngeal nerve
  injury postop based on clinical symptoms is not
  reliable.
• Up to 1/2 of patients with RLN damage may have no
  or minimal voice changes post op with a
  unilateral RLN lesion.
• Post -op voice changes can occur without nerve
  lesion, may be result of superior LN damage or
  intubation alone
• In redo or cancer related thyroid surgery,
  request pre-op examination by ENT prior to
  surgery

• Farling, P.A. Thyroid Surgery. British Journal
  of Anaesthesia, 2000, Vol. 85, No.1, 15-28
• Robertson ML, Steward DL, Gluckman JL, et al.
  Continuous laryngeal nerve integrity monitoring
  during thyroidectomy does it reduce risk of
  injury? Otolaryngology Head and Neck Surgery.
  2004 Nov 131(5)596-600.