About management of anesthetic challenges in huge retro sternal goiter for thyroidectomy

1. HUGE THYROID SWELLING WITH RETROSTERNAL
EXTENSION FOR THYROIDECTOMY.
Dr.G.UMA
Associate Professor
Dept of Anaesthesiology
KIMS & RC
Tamilnadu

2. “It always seems impossible until it’s done”
Retrosternal goitres are defined in many ways,but widely accepted
definition is that 50% of the enlarged thyroid gland is below the
suprasternal notch.
the goitre is graded according to its position in the mediastinum.
As the mediastinum is a confined space, the enlarged gland causes
pressure symptoms ,necessitating the goitre to be removed.

3. INTRODUCTION
Anaesthesia for patients with a large obstructive retrosternal Goiter remains challenging during the entire
perioperative period because of
 difficult intubation
 blood loss
 long duration of surgery
 cardiovascular compromise during manipulation of gland
 Potential risk for total obstruction of the distal trachea after induction
 risk for tracheomalacia after extubation

4. Pre operative preparation
It is an inter disciplinary team process.
Consider the disease process & its secondary effects
Assess the thyroid hormone levels & treat hyper or Hypothyroid status accordingly
Airway assessment and plan how to secure the airway
Pre op assessment of obstructive effects of the Goiter & discussing the management plan
with the surgical team . Cardio thoracic surgeon, ENT surgeon & The Intensivist are part of
the team in case front of neck access,sternotomy & CPB are needed
plan of management of postoperative tracheal collapse if any, has to be discussed with
the surgeon
intensivist to be informed if there is a plan of elective postop ventilation

5. Investigations
• biopsy – if a malignant tumour ,may have infiltrated the airway causing tumour
collapse on induction causing more airway obstruction and hypoxia.
• A benign goiter may not cause CVS collapse at Induction. But causes external
compression only , so lifting the swelling may help in passing ET tube in to
the Trachea
• Thyroid function tests
• blood sugar
• complete hemogram
• blood grouping and cross matching
• serum Electrolytes
• coagulation profile
• RFT & LFT

6. • Indirect Laryngoscopy to assess vocal cord movements.
• Bronchoscopy to assess the dynamic obstruction , the narrowest diameter of the
Trachea.(ENT surgeon standby for emergency tracheostomy/or rigid bronchoscope to
secure airway if other methods fail at induction.)
• X Ray chest to assess mediastinal mass size and compression.
• X Ray neck AP & Lateral view to assess Tracheal deviation and compression.
• Ultrasound of airway for narrowest part of trachea, compression and deviation.(to keep
appropriate Endotracheal tubes ready).
• CT , CE CT & MRI to assess tracheal deviation, narrowest part of trachea, extent of
swelling in to the thoracic cavity and compression of vessels (sternotomy whether needed,
Cardiothoracic surgeon to be informed if necessary preop itself).
• SpO2 in room air, both in supine and sitting posture.

7. Plain Xray neck& Chest AP and Lateral views

8. CT,CE CT & MRI studies

9. IDL, Bronchoscopy & Ultrasound studies

10. • General clinical & all systems examinations
• Examination of the swelling-size, able to feel lower border of swelling, Tracheal
deviation
Airway examination –1.any difficulty in mask ventilation, laryngoscopy,
intubation, front of neck access.
2.Any significant airway obstruction pre op itself
3. Mallampatti grading
4. Neck mobility
5. TMD & TMJ movements
ASA grading
Documentation of Plan of Airway management

11. Explain the risks of difficult airway, emergency tracheostomy may be needed , awake
fibre optic intubation, consequences of hypoxia and cardiovascular complication that may
happen on induction and elective postop ventilation to the patient and get informed written
consent. Plan A & alternate plan to secure airway to be ready.
Multi disciplinary team to be ready in the operation room.

12. Perioperative management
• Premedication with Proton pump inhibitor, Glycopyrrolate and steroids.
• Avoid sedatives.
• Two wide bore IV cannulas. Arterial line & femoral venous cannulation if Patient may
need to go on CPB.
• Pre oxygenation for 3 minutes is essential and mandatory.
• ECG,NIBP,EtCo2,Puse Oximetry & Temperature monitoring is mandatory.
• Proper airway preparation with 4% lignocaine nebulisation,2% lignocaine nasal
pack,lignocaine Spray to posterior pharynx.
• In huge swellings nerve blocks may not be possible.then use SAGO (Spray as you
go)technique if Awake fibre optic intubation is planned.

13. Perioperative management
• Induction - Intravenous Induction is better.
• Inhalation induction takes time & timing of laryngoscopy is to be controlled crucially.
• Use Flexometallic ET tubes or Microlaryngeal ET tubes.
• Special ET tubes are available,which help to assess nerve injury intraoperatively itself.
• Analgesics-Opioids like fentanyl. Thoracic epidural.
• Muscle relaxant -vecuronium
• Volatile agent-Isoflurane with Closed circuit.
• Good analgesia and deeper planes of anesthesia to be provided prior to sternotomy.
• IV fluids and Blood transfusion according to the need is to be given.

14. Prior to Extubation
• Leak test prior to extubation will reveal Tracheomalacia if present.
• Vocal cord movements by Laryngoscopy/Fibreoptic Bronchoscopy.
• Prolonged surgery-any need for elective post operative ventilation.
• Steroids prior to extubation.
• Calcium IV supplemention as needed.
• Adrenaline nebulization in suspected airway edema.
• Extubation of a fully conscious patient after leak test & verifying bilateral vocal cord movements.
• Post extubation steroids and nebulization to continue for 48 hours.

15. Nerve injury
Prior to Exubation assess vocal cord movements on
laryngoscopy.
Fiberoptic Bronchoscopy to document vocal cord
movements.
If nerve injury is suspected,extubate and observe.
Elective Tracheostomy if there is stridor.

18. Tracheomalacia
Elective postop ventilation for 24 hours. Reassess &
trial Extubation.
On table elective Tracheostomy. Reassess after 48
hours.

19. I remain most grateful for the rapt attention with which you attended this lecture.
I’m confident that you’ve learned something from it.
Any Questions?
Huge Thyroid swelling with retrosternal extension poses a unique challenge of
difficult and shared airway, possibility of airway compromise Perioperatively and
complications. Keep in mind the clinical status of the patient and the available
resources. Planning ,optimisation & team work is the prerequisite for a successful
outcome. In hospital Protocols have to be developed at each center for safe
management of such patients.

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22. Thank you All