Prof. A K Sethi’s EORCAPS 2008 Prof.

A K Sethi’s EORCAPS 2008

THYROID SWELLING WITH

HYPERTHYROIDISM CASE PRESENTATION

¾ Om Piari 64 F

¾ House wife

S.K.MALHOTRA
¾ PRESENT COMPLAINTS
- Swelling Neck - 25 yrs
- Dilatation of veins, front of chest - 1yr

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

HISTORY OF PRESENT ILLNESS PAST HISTORY

¾ Noticed small swelling in front of neck 25 yrs back ¾ Pt. underwent radical mastectomy for Ca breast 1yr back under
¾ Gradually increased in size from pea-nut to present size GA – Uneventful
¾ On Tamoxifen since 1 yr
¾ H/O dyspnoea when lying down 3 yrs
¾ H/O Heat/cold intolerance 2 yrs
FAMILY HISTORY
¾ H/O Palpitation 2 yrs
No similar complaints in family
¾ No H/O
- Pain, discharge PERSONAL HISTORY
- Fever - Married, post-menopausal
- Weight gain/loss - Non smoker
- Change in voice - No alcoholic
- Difficulty in swallowing - Bowel and bladder habits --normal
¾ No H/O TB, DM, Asthma, known hypertensive
¾ On medication - Tab. Atenolol 25 mg BD

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

GENERAL PHYSICAL EXAMINATION AIRWAY

¾ Mouth opening - 3 fingers

¾ Average built
¾ Wt 68 kg Ht 160 cm ¾ MMP - grade III
¾ No pallor, jaundice, oedema, cynosis, lymphadenopathy
¾ Dentition - normal
¾ Pulse 82/min, regular, good volume
¾ All peripheral pulses felt ¾ Mento-thyroid distance - 6 cm
¾ No radio-radial / radio-femoral delay
¾ Neck extension - normal
¾ BP 128/76 (RUL, Supine)
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
Examination of swelling..contd

EXAMINATION OF SWELLING
Palpation

¾ Local temp.not raised

Inspection
¾ All the borders except lower border are palpable
- Butterfly shaped, midline swelling
- Extending from upper border of ¾ Getting below swelling not possible
thyroid cartilage and between two ¾ Trachea not palpable
sternocleidomastoid ms
- Size 9x10 cm ¾ Pemberton’s sign -ve
- Surface smooth (distended neck and head veins, inspiratory stridor and increased JVP upon
- Moves with deglutination and raising of the patient's both arms above head)
protrusion of tongue
- Distended veins- infront
- Skin over swelling - normal
Auscultaion
- No visible pulsation No bruit over the swelling

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

SYSTEMIC EXAMINATION
X-ray Chest
Abdomen
¾ Soft, non-tender
¾ No organomegaly
¾ No free fluid
¾ Bowel sounds heard

¾Chest / CVS
NAD

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

X-ray Neck (Lat)

INVESTIGATIONS

X-ray Chest

¾ Soft tissue shadow

¾ Trachea shifted to right
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

CT Scan
CT Scan
¾ Trachea deviated

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

CT Scan
ECG
¾ Multinodular goitre with
retrosternal extension

¾ Causing mass effect on

trachea,bracheocephalic
veins and branches of arch
of aorta.

¾ With multiple superficial

collateral channels

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Thyroid Function Tests Biochemistry

 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
ANATOMY
¾ In endemic areas, the incidence of goitre ?
-Butterfly-shaped organ
15–30% of the adult population
-Composed of two cone-like lobes
-lobus dexter (right lobe)
¾ Anaesthetic implications of Thyroid diseases ? - lobus inister(left lobe)
Hypothyroidism, hyperthyroidism and conditions requiring -
thyroidectomy -Connected with the isthmus

-Situated on anterior side of neck

¾ Patients with considerable risk ? -Lying against and around larynx and
Uncontrolled myxoedema/ hyperthyroidism presenting as an trachea
-Reaching posteriorly oesophagus and
emergency
carotid sheath
. Anaesthesia for thyroidectomy is complicated by ?
Airway problems --Starts just below the laryngeal prominence
(Adam’s apple)
-Pay attention to preoperative assessment of the airway
- Should be able to deal with airway complications periop. -Extends inferiorly to 4th to 6th tracheal ring

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Anatomy…contd
Anatomy…contd

¾ Thyroid gland is covered by fibrous sheath, composed of an ¾ Blood Supply: from the superior thyroid artery, a branch of
internal and external layer the external carotid artery, and the inferior thyroid artery

¾ Covered anteriorly with infrahyoid muscles and laterally with ¾ Venous blood: drained via superior thyroid veins, draining in
sternocleidomastoid muscle. the internal jugular vein, and via inferior thyroid veins,
draining in the left brachiocephalic vein.
¾ Posteriorly, the gland is fixed to the cricoid and tracheal
cartilage ¾ Nerve Supply : by sympathetic nerve input from superior
cervical ganglion and cervicothoracic ganglion of sympathetic
trunk
¾ On the posterior side of the lobes there are on each side two
parathyroid glands Parasympathetic nerve input from superior laryngeal nerve
and recurrent laryngeal nerve.
¾ Thyroid weighs - 18-60 grams in adults .

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Blood supply and Venous drainage PHYSIOLOGY

Primary function of thyroid ?

is production of hormones
¾ Thyroxine (T4)
¾ Triiodothyronine (T3)
¾ Calcitonin

¾ Up to 80% of the T4 is converted to T3 by peripheral organs such as

the liver, kidney and spleen

¾ T3 is about ten times more active than T4

T3 and T4 production and action?

¾ Thyroxine (T4): synthesised by follicular cells from free tyrosine and
on tyrosine residues of protein called thyroglobulin (TG).
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Physiology…contd Physiology…contd
¾ Brain Cells are a major target for the thyroid hormones
¾ Upon stimulation by thyroid-stimulating hormone (TSH), T3 and T4
follicular cells reabsorb TG and proteolytically cleave the
iodinated tyrosines from TG, forming T4 and T3 (in T3, one ¾ Thyroid hormones play a particularly crucial role in brain
iodine is absent compared to T4), and releasing them into development during pregnancy
blood
¾ A transport protein (OATP1C1)
¾ Deiodinase enzymes convert T4 to T3 - Important for T4 transport across the Blood brain
barrier
¾ Thyroid hormone that is secreted from gland is -
90% T4 and 10% T3 ¾ Another transport protein (MCT8)
- Important for T3 transport across brain cell memb.

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Physiology…contd
¾ T4 and T3 are partially bound to HYPERTHYROIDISM
- thyroxine-binding globulin, ¾
- transthyretin Thyrotoxicosis affects:
- albumin.
2% of women
¾ Only a small fraction of the circulating hormone is 0.2% of men
free (unbound)
- T4 0.03% T3 0.3%.
¾ The prevalence is two per 1000.
- Only the free fraction has hormonal activity

¾ Thyroid hormones cross cell membrane and bind to ¾ Subclinical hyperthyroidism is:
intracellular receptors (α1, α2, β1 and β2), which act with the
retinoid X-receptor to modulate DNA transcription six per 1000

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Hyperthyroidism…contd

Of importance to the anaesthetist are the

Classical features include ? cardiovascular effects including :
- Anxiety
- Skin -warm, moist ¾Atrial fibrillation,
- Exophthalmos ¾Congestive cardiac failure
- Heat intolerance ¾Ischaemic heart disease.
- Diarrhoea
-Hyperactivity ¾Thrombocytopaenia may be associated with
-Weight loss thyrotoxicosis.
-Tremors
 Prof. A K Sethi’s EORCAPS 2008
¾ To prevent dreaded complication of ‘thyroid storm’,
- patients should be euthyroid before surgery
¾ This is achieved by use of antithyroid drugs:
- Propylthiouracil (PTU) 200 mg 8 hrly
- Methimazole 20 mg 8 hrly
¾ These drugs block the synthesis of thyroxine
- but take 6–8 weeks to work
Prof. A K Sethi’s EORCAPS 2008
¾ Anaesthetic drugs:
affected by hypermetabolic state of hyperthyroidism
¾ For example, clearance and distribution of propofol
-- increased in hyperthyroid patients
¾ When total intravenous anaesthesia is used:
- propofol infusion rates should be increased to
reach anaesthetic blood concentrations.
Prof. A K Sethi’s EORCAPS 2008
Thyroid crisis…contd
¾ Thyroid crisis still occurs in uncontrolled patients
as a result of a trigger, such as
-Surgery
-Infection
-Trauma
¾ Supportive management of thyroid crisis ?
- Hydration
- Cooling
-Inotropes
- Steroids
Prof. A K Sethi’s EORCAPS 2008
¾ Beta-blockers, particularly propranolol (40-80 mg 8 hrly)
- used to reduce the effects of
- thyrotoxicosis
- effective in the acute preoperative phase
¾ Longer-acting beta-blockers
- e.g atenolol or nadolol
- may achieve better control of symptoms
Prof. A K Sethi’s EORCAPS 2008
THYROID CRISIS ?
Hypermetabolic crisis known as ‘thyroid storm’
- is frequently mentioned in textbooks of anaesthesia
- but is now rarely seen
- because of the widespread use of anti-thyroid drugs,
(such as carbimazole, propylthiouracil and beta-blockers)
Prof. A K Sethi’s EORCAPS 2008
Thyroid crisis…contd
First-line of treatment ?
¾ Beta-blockade, (using propranolol)
Antithyroid drugs
¾ Esmolol was successful in treating a child of 14 months who
developed a thyroid crisis 3 h after thyroidectomy
¾ . An 85-yr-old with multinodular goitre and severe
thyrotoxicosis was also managed with esmolol.
¾ An acute thyroid crisis on induction of anaesthesia, which was
mistakenly diagnosed as malignant hyperthermia, was treated
successfully by boluses of dantrolene 1 mg kg –1.
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
Thyroid crisis…contd Thyroidectomy

¾ Christensen and Nissen reported the successful use of Indications for thyroidectomy ?
dantrolene to treat thyroid crisis in a child who had not
responded to traditional measures.
¾ Proven or suspected thyroid malignancy
¾ Obstructive symptoms:
¾ Since thyroid hormones sensitize the adrenergic receptors to - Dysphagia
endogenous catecholamines, - Dyspnoea
Magnesium sulphate, theoretically, seems to be a - Hoarseness
useful drug. ¾ Retrosternal goitre, even in the absence of obstruction;
¾ Hyperthyroidism - unresponsive to medical treatment
¾ Magnesium reduces the incidence and severity of
dysrhythmias caused by catecholamines ¾ Recurrent hyperthyroidism

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Indications…contd Preoperative assessment

¾ Take general history.

¾ Identify the abnormalities of thyroid function.

¾ Cosmetic reasons
¾ Assess features of hyperthyroidism
¾ Anxiety (patients with a small goitre may
¾ Seek evidence of other medical conditions ,especially
insist on having it removed)
- Cardiorespiratory disease
¾ Patients with Hashimoto’s disease and goitre respond to
- Endocrine disorders
thyroxine ( For example, patients for thyroidectomy with medullary
cancer may have an associated phaeochromocytoma
-- but thyroidectomy is indicated if there is any
suspicion of superimposed lymphoma. .

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Preoperative assessment…contd Preoperative assessment…contd

¾ Problems with airway management

main concern of the anaesthetist in a Other assessments of the airway
patient with goitre
- Distances between incisors
¾ History of respiratory difficulties, - Thyromental distance
e.g positional dyspnoea - Degree of protrusion of the lower teeth
associated with a degree of dysphagia. - Head and neck mobility
- Observation of pharyngeal structures
¾ Patients with retrosternal goitre (MMP)
may exhibit signs of vena caval obstruction.
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Preoperative assessment…contd
Preoperative assessment…contd
Chest x-ray
Routine investigations ?
- Thyroid function tests
- Haemoglobin
- White cell and platelet count
- Urea and electrolytes
- Serum calcium
- Chest x-ray ( for tracheal deviation/compression)
- Indirect laryngoscopy (by ENT surgeon)
- Any preoperative vocal cord dysfunction Showing gross tracheal compression and deviation
- May alert for impending difficult intubation by a retrosternal goitre.

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Preoperative assessment…contd
Preoperative assessment…contd

¾ The usefulness of respiratory function tests is debatable

.
- Respiratory flow volume loops showed upper airway
obstruction in 33% patients with thyroid enlargement

-This was unrelated to the type or size of goitre

¾ Following a careful history, examination and investigations,

the anaesthetist can be in a position to discuss with the patient
the various options for airway management
Reconstructed CT scan.

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Preoperative assessment…contd
ANAESTHETIC TECHNIQUE
Options for airway management ? REGIONAL ANAESTHESIA

¾ It is possible to perform thyroidectomy under bilateral deep or

- Straightforward intravenous induction
superficial cervical plexus blocks
- Inhalational induction
- Fibreoptic intubation.
¾ Complications of this technique,
- Vertebral artery puncture,
¾ The patient should be warned what to expect,
postoperatively - Epidural subarachnoid spread
- Bilateral phrenic nerve block.
¾ Anxiolytic premedication prescribed.
¾ Epinephrine containing local anesthetic solutions should be
avoided.
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
Regional anaesthesia…contd
GENERAL ANAESTHESIA

¾ Thyroidectomy under regional anaesthesia is not

routinely practised in India or western countries General anaesthesia with tracheal intubation and
muscle relaxation
¾ In some parts of the world, thyroidectomy is
performed under acupuncture, with or without - is the most popular anaesthetic technique for
supplementary analgesics
thyroidectomy.
¾ Hypnosedation, a combination of hypnosis and light
sedation, has been suggested for thyroidectomy

Prof. A K Sethi’s EORCAPS 2008

General anaesthesia….contd Prof. A K Sethi’s EORCAPS 2008
General anaesthesia….contd

¾ The laryngeal mask airway (LMA)

has been used with spontaneous respiration and IPPR in ¾ Euthyroidism should be established preoperatively
thyroid surgery
¾ In elective cases:
¾ Contraindication to use of LMA: - Antithyroid drugs (carbimazole) for 6-8 weeks
-Tracheal narrowing and/or deviation. - Potassium iodide 60 mg t.i.d. for 10 days

¾ Use of the LMA allows ¾ In emergency cases

Vocal cord movement to be seen via a fibreoptic laryngoscope use of an i.v.beta blocker, ipodate, dexamethasone and
(when rec.laryngeal nerve is stimulated )
PTU is necessary
¾ However, there is a risk
LMA will be displaced during surgery and laryngospasm ¾ We should be prepared to manage thyroid storm,
occurs ( due to surgical manipulation.) -especially in uncontrolled or poorly controlled patients
(who present for emergency surgery.)

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

General anaesthesia….contd General anaesthesia….contd

¾ Premedication
barbiturate, benzodiazepine, narcotic Intubation
¾ Trachea is intubated using conventional laryngoscopy.
Atropine should he avoided
- may precipitate tachycardia
- alter heat-regulating mechanisms ¾ Tracheal tube should not kink when it attains body
temperature during prolonged surgery
¾ Induction
Thiopentone, secondary to its thiourylene nucleus, decreases
conversion of T4 to T3
- have a advantage over propofol
¾ So a reinforced tube should be considered

Succinylcholine and the nondepolarizing muscle relaxants with limited

hemodynamic effects (e.g., vecuronium, rocuronium)
- safe for intuhation
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
General anaesthesia….contd General anaesthesia….contd

¾ Eye protection
¾ ‘North-polar’ tracheal tubes: eyedrops, lubricant, eye pads
- important, esp. for pts with proptosis
-An alternative
-Away from the surgical field. ¾ lntraoperative monitoring
ECG, NIBP, SpO2,EtCO2,Temp,
¾ Nasal tracheal tubes may also be used
Need for invasive monitoring - determined on an individual basis
(vasoconstriction is required to prevent epistaxis.)

¾ Establish adequate anesthetic depth

¾ Wise to select a small reinforced tracheal tube - to avoid Symp.N.Syst. Responses
if there is any degree of tracheal compression
¾ Drugs that stimulate the SNS should he avoided
e.g ketamine, pancuronium,, ephedrine, epinephrine

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Maintenance:
-Inhalation agents (Isoflurane, sevoflurane)
-Nitrous oxide and opioids are safe ¾ Removal of the thyrotoxic gland does not mean immediate
resolution of thyrotoxicosis.
¾ Muscle relaxants chosen based on - beta-blocker must be continued in the postop.
-Their interaction with the SNS period
- Hemodynamic effects.
¾ Antithyroid drug therapy can be discontinued.
Intraoperative hypotension
direct-acting vasopressor (phenylephrine) preferred ¾ Thyroid storm and malignant hyperthermia can present
with similar intraoperative and postoperative signs and
symptoms (i.e., hyperpyrexia, tachycardia,
Reversal hypermetabolism).
- Glycopyrrolate instead of atropine + neostigmine
¾ Differentiation between the two may be extremely
difficult.

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Unexpected difficult intubation

¾ The preop. detection of thyrotoxicosis ¾ Occasionally, the larynx is not easily seen,
so, anaesthetic team must be prepared to cope with
Tremors, diaphoresis, fatigue, tachypnea, unexpected difficult intubation.
tachycardia, fever, an enlarged thyroid
--- is very important Items which should be available
¾ Thyrotoxicosis is very rare in children ¾ Various sizes of tracheal tubes
¾ Gum elastic bougies
¾ Levering laryngoscope
¾ Regardless, thyrotoxicosis should be considered in ¾ Straight-bladed laryngoscopes
differential diagnosis of malignant hyperthermia in ¾ Intubating LMA
any age group. ¾ Intubating fibrescope
¾ Some means of trans-tracheal ventilation.
 Prof. A K Sethi’s EORCAPS 2008
Expected difficult intubation
¾ If preoperative airway assessment and/or inability of the ENT
surgeon to see vocal cords by indirect laryngoscopy have
predicted any difficulty with intubation,
- then we must have a clear strategy for intubation
¾ 6% of tracheal intubations for thyroid surgery are difficult
. - head resting on a padded ‘horseshoe’ or Whitlock headrest
¾ Whenever there is concern that the airway will be lost if
anaesthesia is induced,
-- awake fibreoptic intubation is method of choice.
¾ Traditional technique of inhalational induction has regained
acceptability
--- following introduction of sevoflurane
Prof. A K Sethi’s EORCAPS 2008
Positioning the patient…contd
¾ A 25° upward tilt of the head will assist venous drainage,
although this should be performed with careful
attention to arterial pressure,
(particularly in patients who are on beta- blockers)
¾ Finally, slight head extension will allow the surgeon excellent
access to the thyroid gland.
Prof. A K Sethi’s EORCAPS 2008
Postoperative care
¾ Residual neuromuscular block is reversed and patient is
allowed to recover from anaesthesia.
¾ If there has been any concern during dissection of the
recurrent laryngeal nerve, the vocal cords are checked and
the surgeon reassured.
¾ A fibreoptic endoscope may be used to view the vocal cords
atraumatically.
¾ When adequate spontaneous respiration and laryngeal
reflexes have returned, the patient is extubated.
Prof. A K Sethi’s EORCAPS 2008
Positioning the patient
¾
¾ After intubation, the position of tracheal tube is checked and
secured
¾ Patient is positioned with a sandbag between shoulder blades
¾ Both arms are placed by the side,
as the surgeon will stand on either side of the patient.
¾ A long connector for the i.v. infusion allows access from the foot
of the bed
Prof. A K Sethi’s EORCAPS 2008
Surgical Technique
¾ skin infiltrated with 10–20 ml , 0.5% bupivacaine and
epinephrine 1:200 000.
¾ Skin flaps raised and strap muscles separated in midline.
¾ It is rarely necessary to divide the strap muscles.
¾ Upper pole mobilized and superior thyroid vessels ligated.
¾ Mobilization of lobe completed and parathyroid glands and
recurrent laryngeal nerve identified and protected during
dissection of thyroid from trachea.
¾ Haemostasis is secured and strap muscles and platysmal
layers apposed.
¾ The skin is closed with staples.
Prof. A K Sethi’s EORCAPS 2008
Thyroidectomy in special situations
Hyperthyroidism
¾ Thyroidectomy is offered to patients with hyperthyroidism when medical
treatment proves inadequate.
¾ Patients should be euthyroid before surgery.
¾ Approximately three patients per 1000 are unable to take antithyroid drugs
because of serious adverse reactions like hepatitis, aplastic anaemia
¾ Clinical manifestations of thyrotoxicosis are usually controlled by beta-
blockers
¾ Beta-blockers alone may be adequate preparation for thyroidectomy.
 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
Retrosternal goiter
Huge goitres
¾ Huge goitres may have a neck circumference of about 60 cm

¾ While these goitres may have a dramatic appearance, they often present Retrosternal enlargement usually causes compression of mediastinal
fewer problems than smaller retrosternal goitres. structures

¾ Dyspnoea, choking and hoarseness may occur.

¾ The problems associated with huge goitres:
- difficult intubation ¾ Dysphagia is the most common oesophageal symptom
- large blood loss,
- tracheomalacia (post-operative) ¾ Superior vena caval syndome can occur

¾ . Retrosternal goitres may also cause

¾ Use of a small armoured tracheal tube is recommended to negotiate the - Cerebral hypoperfusion as a result of arterial compression -
compressed and deviated trachea. Recurrent laryngeal nerve palsies,
- Horner’s syndrome,
- Pleural effusions,
¾ Unarmoured tubes may soften during these prolonged procedures. - Pericardial effusions.

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Haematoma
¾
Postoperative complications Postoperative haemorrhage is catastrophic, but can be avoided by
meticulous haemostasis.

¾ Recovery ward staff should be experienced at observing early

Extubation problems signs of haematoma so that both surgeon and anaesthetist can be
¾ alerted.
incidence of respiratory complications at tracheal extubation and in the
recovery room is greater than that at intubation
¾ Prompt decision-making is important and early re-intubation is
¾ These complications include oxygen desaturation, laryngospasm and recommended.
respiratory obstruction.

¾ Possible preventive interventions:
- Extubation during relatively deep anaesthesia,
- Administration of intravenous narcotics, for example alfentanil
- Lidocaine may be administered intravenously or topically, or
even prestored in the cuff of the tracheal tube.
¾ Obviously, later the intubation is performed, more difficult it
becomes as the haematoma expands and compresses the airway
.

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Recurrent laryngeal nerve damage…contd

Recurrent laryngeal nerve damage

¾ Injury to the recurrent laryngeal nerve can occur by a
number of mechanisms, including ischaemia, contusion,
traction, entrapment and actual transection.
¾ The incidence of damage to the recurrent laryngeal nerve is
3–4%.
¾ There is a greater risk of nerve damage during surgery for
malignancy
¾ Anaesthetist should to observe the movement of the vocal
cords at the end of surgery.
¾ Rather than using a Mackintosh laryngoscope, vocal cords
may be observed using a fibrescope.
¾ A fibreoptic bronchoscope can be used to observe the vocal
cords via an LMA during surgery.
¾ Succinylcholine is used to intubate the trachea and no further
muscle relaxant is used.
¾ Bilateral vocal cord paralysis will lead to stridor at tracheal
extubation.
¾ Re-intubation will be required and tracheostomy should be
considered.
¾ Traditional treatments of vocal cord paralysis include
intracordal injection, laryngeal framework surgery, thyroplasty
and laryngeal re-innervation.
 Prof. A K Sethi’s EORCAPS 2008

Tracheomalacia
¾
Tracheal collapse following thyroidectomy results from
prolonged compression of the trachea by a large goitre.

¾ It is a life-threatening complication, which should be

considered before extubation, and management strategies
should be available
.
¾ The absence of a leak around the deflated cuff of the tracheal
tube should alert the anaesthetist to the possibility of
tracheomalacia.

¾ Management of tracheomalacia requires urgent re-intubation,

possibly tracheostomy and some form of tracheal support with,
for example, ceramic rings.