Title: Airway Complications and Management after Thyroidectomy
1Airway Complications and Management after
Thyroidectomy
UT AnesthesiologyGrand RoundsMarch 31st 2005
- Jose M. Soliz, M.D.
- Christiane Vogt-Harenkamp, M.D.
2Case 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.
3Case History
- Medications none
- Allergies none
- Past medical history none
- Past surgical history right hemithyroidectomy
six weeks prior. uneventful, no noted
complications
4Case 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.
5Physical 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
6Perioperative 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
7Extubation
- Cuff deflated, tube pulled. Patient began
breathing low tidal volumes with audible stridor.
Differential Diagnosis? What to do next?
8Post-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.
9Post-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
10Post-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
11Airway Complications and Management after
Thyroidectomy
- Anatomy
- Complications and management
- Intubation related and post-op
complications - Diagnosis and prevention
- Therapeutic measures
- Take home message
- Focus on laryngeal nerve palsies
12 13Airway Complications and Management after
Thyroidectomy
- 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
14Airway Complications and Management after
Thyroidectomy
- 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
16Airway 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 18(No Transcript)
19Airway 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
20Airway 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)
21Airway 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)
22Airway 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
23Airway 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)
24Airway 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
25Airway 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)
26Airway 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)
27Airway 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
28Airway 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.
29Airway 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) -
30Airway 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) -
31Airway 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
32Airway 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
33Take 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.