|Year : 2021 | Volume
| Issue : 1 | Page : 41-44
Delayed tracheal rent following total thyroidectomy
Avanthi Subramanian, Sunil Rajan, Lakshmi Kumar
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
|Date of Submission||15-Aug-2020|
|Date of Acceptance||14-Dec-2020|
|Date of Web Publication||29-Apr-2021|
Dr. Sunil Rajan
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
Tracheal injury associated with thyroidectomy is rare. We report the case of a 41-year-old lady who underwent total thyroidectomy for multinodular goitre. The surgery was uneventful. On postoperative day (POD) 8, she complained of cough followed by a ‘give-way’ sensation over her neck. On POD 10, she presented with dyspnoea after a sudden bout of cough with blood-tinged sputum, stridor and swelling over the surgical site. Computerised tomographic (CT) scan showed a defect on the right anterolateral wall of the trachea at the level of C6 vertebra and subcutaneous emphysema. She underwent emergency tracheostomy under general anaesthesia. Intraoperatively, a 5 mm × 10 mm tracheal rent was visualised between the first and second tracheal rings over the right side with surrounding unhealthy tracheal cartilages. The defect was closed with strap muscles and surgical tracheostomy performed between the 4th and 5th tracheal rings. In patients presenting with respiratory distress and subcutaneous emphysema following thyroid, mediastinal or anterior cervical approach surgery, a high index of suspicion of delayed tracheal injury must be entertained. An X-ray, and more importantly a CT imaging, may be conclusive to identify the site of tracheal rupture. The decision to follow conservative management or consider urgent surgery will depend on patient presentation.
Keywords: Complication, post-thyroidectomy, rent, rupture, trachea
|How to cite this article:|
Subramanian A, Rajan S, Kumar L. Delayed tracheal rent following total thyroidectomy. Airway 2021;4:41-4
| Introduction|| |
Thyroidectomy is a relatively safe and commonly performed surgical procedure. Though not without complications such as compressive haematoma, hypocalcaemia, recurrent laryngeal nerve injury, tracheomalacia and wound infection, the overall incidence of complications is 3% and the mortality rate following surgery is close to 0%. Nevertheless, in the event of tracheal injury with respiratory compromise, airway control is of primary concern in order to proceed with further management. We present the case of a 41-year-old lady who underwent total thyroidectomy and presented to the emergency room (ER) on POD 10 with dyspnoea, cough and stridor with radiological evidence of a tracheal rent.
| Case Report|| |
A 41-year-old lady underwent total thyroidectomy for multinodular goitre, with radiological features and tissue diagnosis suggestive of Hashimoto's thyroiditis. After induction of general anaesthesia (GA) as per standard protocol, orotracheal intubation was performed following gentle laryngoscopy lasting <15 s at the first attempt by an experienced anaesthesiologist. A 7.0 mm ID, high-volume, low-pressure cuffed endotracheal tube (ETT) was used. Anaesthesia was maintained with an oxygen-air mixture (FIO2 0.5) and isoflurane with volume control ventilation. Intraoperative muscle relaxation was provided with intermittent boluses of atracurium. Fentanyl was used as an analgesic and tracheal cuff pressure was maintained below 25 cm H2O.
The surgery was uneventful; tracheal rings appeared healthy with no signs of tracheomalacia and there was no injury to the trachea. Prior to closure, no air leaks were observed at the surgical field on administration of Valsalva manoeuvre, ruling out intraoperative tracheal injury. The wound was closed in layers with a suction drain, and the patient was extubated at the end of surgery. The suction drain was removed on the 2nd postoperative day (POD). The patient was discharged on POD 5. She came for review to the outpatient department on POD 8 and reported that following a bout of cough 2 days prior, she had felt a ‘give-way’ sensation over her neck. She had not sought immediate medical advice as no distressing symptoms were present. On examination, the wound was found healthy and there was no tenderness. She was reassured and sent home.
On POD 10, she presented to the ER with dyspnoea after a sudden bout of cough and stridor since the previous night. She also noticed a change in the size of swelling over the surgical site with cough and had one instance of blood-tinged sputum. She was brought to the operation theatre in a propped-up position with oxygen support by the ER team. Her saturation was 98%, and upper airway examination was normal. Auscultation revealed normal vesicular breath sounds bilaterally. Crepitus was palpable over the left side of the neck.
Computerised tomographic (CT) scan showed a defect on the right anterolateral wall of trachea at the level of C6 vertebra corresponding to the space between the 1st and 2nd tracheal rings with subcutaneous emphysema [Figure 1]. She was taken up for emergency tracheostomy under GA. Rapid sequence induction was performed, and the airway was secured under videolaryngoscopy with a 7.0 mm ID ETT. Flexible bronchoscopy was performed to confirm that the distal end of ETT was positioned just above the carina and probably bridged the area of the suspected tracheal rent. Volume control ventilation with low tidal volume (350 mL) and positive end-expiratory pressure (4 cm H2O) was delivered. Intraoperatively, a 5 X 10 mm size tracheal rent was visualised between the 1st and 2nd tracheal rings over the right side with surrounding unhealthy tracheal cartilages with no obvious infection of the thyroid bed [Figure 2]. The defect was closed with strap muscles and surgical tracheostomy was performed between the 4th and 5th tracheal rings. Tracheostomy was performed only at the end of surgery as there was no air leak through the tracheal rent after intubation and intraoperative ventilation was adequate. She continued to have an episodic cough which was managed with suctioning and nebulisation. On POD 15, the polyvinyl chloride tracheostomy tube was exchanged for a Jackson metal tracheostomy tube, and the patient was discharged with proper instructions. After 6 weeks, decannulation was done and the patient had an unremarkable recovery.
|Figure 1: Computerised tomographic image of tracheal rupture at the level of C6 vertebra|
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| Discussion|| |
Tracheal injury associated with thyroidectomy is in itself a rare event with an incidence of 0.06% according to Gosnell et al. who reviewed 11,917 patients. Out of the 7 inadvertent perforations, 6 patients had a benign pathology and all instances were identified intraoperatively and managed with primary closure, despite which one patient presented with subcutaneous emphysema, managed conservatively, and another developed bilateral tension pneumothorax requiring closed-tube thoracostomy and reoperation. Most commonly, the site of injury is the posterior lateral cartilage–membranous junction near the ligament of Berry because of direct trauma, which was recognised and managed intraoperatively.
Delayed tracheal injury is even more rare and only a few case reports exist in literature where the presentation may be days to weeks following surgery. In the 18 reported cases in literature, the median time to presentation was POD 8 and the longest time to presentation was 40 days. The most common presenting symptoms were neck swelling and subcutaneous emphysema. Risk factors that can predispose to tracheal injury may be classified as preoperative, intraoperative and postoperative. Preoperative factors include female gender, radiation to the neck, thyrotoxic goitre, long-term tracheal compression by a large goitre and subsequent tracheomalacia. Intraoperative factors include prolonged intubation and elevated cuff pressure, leading to reduction of blood supply to the tracheal mucosa that results in necrosis. Difficulty in defining the plane of dissection in patients with multinodular goitre (which is usually characterised by repeated cycles of hyperplasia, degeneration and fibrosis) often necessitates the use of diathermy that could prove dangerous when dissecting around the trachea. In the postoperative period, a persistent uncontrolled cough and infection leading to necrosis can be another risk factor.
A well-hypothesised theory for delayed tracheal rupture is devascularisation or disruption of blood supply of the trachea. Though primary vascular supply arises posteriorly, the anterior and lateral cartilaginous tracheal wall is dependent on an extensive submucosal plexus of arteries that penetrate intervening tracheal rings. Tracheal laceration/rupture due to intubation is also a rare complication with a reported incidence of approximately 0.005% for single-lumen tubes. This would be unlikely in this patient as usually the presentation would be immediate, either intraoperatively or following extubation.
The reason for stridor in our patient could be surgical emphysema and subsequent compression of the airway. However, we were able to hear normal vesicular breath sounds on auscultation, probably because despite a tracheal rent, air passage to the lower airway was maintained, explaining a near-normal saturation as well. Though it is ideal to perform emergency tracheostomy under local anaesthesia, especially when the patient is in stridor, we opted for GA as the patient was very apprehensive and not willing for the procedure under local anaesthesia despite explaining the risks. Moreover, we did not anticipate any major anatomical abnormalities in our patient which might cause any delay in securing the airway.
Early diagnosis and preparedness for tackling a case of delayed tracheal rent is important and a multidisciplinary approach is essential. The main concerns for the anaesthesiologist in managing such cases include securing of airway in a patient with respiratory distress with a cuffed ETT bypassing the rent in order to stop the ongoing air leak into the subcutaneous tissues and maintenance of oxygenation. Follow-up on postoperative recovery of airway especially during decannulation is vital.
| Conclusion|| |
In patients presenting with respiratory distress and subcutaneous emphysema following thyroid, mediastinal and anterior cervical approach surgery, a high index of suspicion of delayed tracheal injury must be kept in mind. An X-ray and/or CT is necessary not only to rule out life-threatening pneumothorax or pneumomediastinum but also to identify the site of tracheal rent and the extent of subcutaneous emphysema. The decision to follow conservative management or urgent surgery will depend on the presenting state of the patient and the extent of injury. Use of a fibreoptic bronchoscope can help to identify the rent and guide the ETT tip beyond the defect to avoid further air leak and also to examine the rest of the tracheobronchial tree.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]