Delayed respiratory distress after thyroidectomy—another challenge for us: a case report

Introduction

Early airway obstruction with acute respiratory distress is a rare but life-threatening complication after total thyroidectomy (TT) (1-3). It could be a potential result of some well-known postoperative complications: recurrent laryngeal nerve (RLN) injury, especially bilateral, with vocal cord paralysis (VCP) and tracheomalacia. Usually, they are seen after the operation and tracheal extubation and are expected from the surgical team. The immediate patient’s management consists of reintubation with or without tracheostomy, followed by definitive treatment (4,5). In comparison, delayed airway obstruction, presenting even days after TT is due to unexpected events, like tracheal compression because of postoperative neck oedema, inflammation or hemorrhage (6-9). These delayed postoperative pitfalls, though infrequent, are possible and unexpected, which represent a critical emergency (10,11). Even Emergency Departments (ED) staff and some senior clinicians are not familiar with the proper case management in face of severe glottic closure and patient asphyxiation (5,10). Moreover, the wrong decision-making could have costed the patient’s life. By presenting this case, we attempt to raise awareness about predicting, diagnosing and managing of asphyxiating patient, also to point a critical importance of gland surgeon expertise for proper decision-making when medically approaching thyroidectomy patient population. We present this case in accordance with the CARE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-22-534/rc).

Case description

Chief complaints

A 47-year-old obese and short neck woman [body mass index (BMI): 42 kg/m²] was admitted in an ED with dramatic respiratory distress and asphyxiation on the twenty-sixth postoperative day after TT.

History of present illness

Underwent TT after a fine-needle biopsy confirmed medullary thyroid carcinoma in enlarged fibrotic multinodular massive goiter causing tracheal compression. Preoperatively, the patient complained of gradual neck stiffness, throat fullness, hoarseness, some degree of orthopnea and having difficulty breathing. At the end of operation, the patient was transferred to post anesthesia care unit with a tracheostomy tube in place, given the extensive and difficult neck dissection with presumed RLN injury and intraoperatively seen tracheomalacia. The rest of the postoperative period was unremarkable and she was discharged from the hospital on the second postoperative day.

Within the next six days, the patient gradually experienced unexpected neck stiffness, throat tightness and dyspnea. Additionally, she reported pain during swallowing and subfebrile condition alongside cough and purulent sputum. Given the existing tracheostomy and the suspected problem with the tracheostomy tube [partial occlusion or an aggravation in long-standing patient’s chronic obstructive pulmonary disease (COPD)], the patient was referred to an otorhinolaryngologist. After an indirect mirror laryngoscopy was performed, a right VCP was noted and the neck was described as visibly swollen possessing a reddish color. In face of new onset dyspnea, without giving proper attention to the postoperative course of this complicated patient, or the possibility of arising surgical complications, the consulting otorhinolaryngologist decided to decannulate and discharge the patient. A few days thereafter, with continued worsening of all complaints especially breathing difficulties, the patient was referred to the pulmonologist, who rose the bronchodilators dosages but without any clinical improvement.

Personal and family history

The patient was diagnosed with hypertension and COPD approximately 10 years ago and has been regularly using Indapamide, Candesartan, Albuterol and Tiotropium bromide.

Physical examination

At the ED, the patient was in critical condition, the breathing was possible only in a tripod position with severe tachy-dyspnea (respiratory rate 48/min), desaturation (SpO₂ 68% at room air) with intense cyanosis, orthodeoxia, orthopnea and prominent biphasic stridor with significantly increased work of breathing, diaphoresis, practically impossible swallowing, tachycardia (144 beats/min), hypertension (186/110 mmHg) and nearly aphonia. Her temperature was 38.9 ℃. Upon neck examination, a post thyroidectomy scar was reddish and the previous tracheostomy was fully obliterated. Also, a large painful submandibular mass with bilateral expiratory rhonchi, purulent sputum and reddish discoloration of the skin were noted.

Laboratory examinations

There was no time for laboratory examinations.

Imaging examinations

Contrast enhanced CT scan of the neck performed in extreme promptitude revealed a large pre-tracheal cavity (30 mm × 21 mm × 24 mm) with spongiform appearance and gaseous content in front of the proximal trachea (Figure 1). A closed glottis with immobile glottic musculature and bilateral VCP (Figure 2) were seen on flexible video-laryngoscopy.

Figure 1 Axial computed tomography scan of the neck: a large pre-tracheal cavity (30 mm × 21 mm × 24 mm) with gaseous content, located in front of the proximal trachea.

Figure 2 Position of vocal cords seen on flexible video-laryngoscopy: (A) inspiration; (B) expiration.

Final diagnosis and treatment

Expecting a “cannot intubate, cannot ventilate” scenario, after 10 min. pre-oxygenation with 100% O₂ in a sitting position with full-face, press-fit mask, resulting in SpO₂ raising up to 78%, the patient was intubated with a rapid sequence induction (200 µg fentanyl, 300 mg propofol, 100 mg succinylcholine). The direct laryngoscopy revealed Cormack Lehane 2^−a grade with fully closed vocal cords, forming only a very small cleft posteriorly. After insertion of a laryngeal endotracheal tube 5.5 ID, which enabled uneventful ventilation, a re-tracheostomy was performed. After opening the pre-tracheal fascia, a stench of decay and an unintentionally retained gauze (a gossypiboma) were noted (Figure 3). Abscess cavity cultures revealed Streptococcus viridans >10⁵. Acute respiratory distress syndrome (ARDS), triggered by sepsis in this particular patient was ruled out by typical clinical picture of a suffocation and a relatively preserved from infection lung parenchyma (Figure 4), seen on the initial plan of CT scan. Following an extensive antimicrobial course, the patient was cured and discharged.

Figure 3 Unintentionally retained gauze (a gossypiboma).

Figure 4 Axial computed tomography scan of the lungs that does not exhibit specific data for acute respiratory distress syndrome.

The patient was successfully decannulated after a month, having made a full recovery from the neck inflammation and achieved gradual voice rehabilitation. Four months later, she still complained of some degree of voice fatigue.

Ethical statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is provided for review by the editorial office of this journal. The study was approved by the Clinical Research Ethics Committee of the University Hospital “Queen Giovanna – ISUL” at the meeting on 31.08.2022 (No. CREC 2022/166).

Discussion

Airway obstruction is the most life-threatening symptom in patients after thyroid surgery. It may result from an RLN injury causing vocal cord immobility, tracheomalacia and compressive oedema or postoperative neck hemorrhage (1,2). It is customary to expect such complications especially if thyroid malignancy, massive goiter, distorted anatomical structures or postoperative inflammation are present (3,12-18). Given the relative scarcity of endocrine surgeons, the bulk of endocrine operations and the postoperative follow-up are performed by medical specialists (general surgeons, otorhinolaryngologists) without interest or prior experience in the field. All the aforementioned issues make TT a tricky operation that remains a source of concern for both patients and medical staff (14,15,18). Obesity, underlying medullary thyroid carcinoma in enlarged fibrotic multinodular goiter and an anatomically short neck, necessitating neck over-extension during surgical dissection, make our patient extremely prone to postoperative airway obstruction (3,13,17). Also, intraoperatively observed tracheomalacia and presumed RLN injury warranted elective tracheostomy. It was performed by the endocrine surgeon, thus initially avoiding post TT airway obstruction and early postoperative respiratory distress. In cases without tracheostomy, this respiratory distress is characteristically seen usually shortly after extubation, which makes this complication predictable, detectable and preventable (8,9). After the initial postoperative improvement, the patient returned in a few days to the ED, because of reappearance of neck stiffness, dyspnea, voice tiredness, subfebrile condition and difficult swallowing. Given the existing tracheostomy, these new complaints are unexpected and alarming. They need attention and clinical clarification. Comorbidity of hypertension and especially COPD or low clinical experience with TT patients could be the reasons why the consulting otorhinolaryngologist neglected the case, even after the right VCP seen by mirror laryngoscopy. As a result of this medical error, the patient was unadvisedly decannulated and discharged home. Thus, the unaddressed and unrecognized neck infection was an issue, which in the next days led to total bilateral vocal cords immobility and delayed life-threatening respiratory distress. Presumably, it will be not the case, if the patient was referred firstly to the gland surgeon. In face of severe tachy-dyspnea, orthodeoxia, desaturation and prominent biphasic stridor, saving the patient’s life required urgent medico-surgical action, because of total physical exhaustion and imminent death (5,6). Although relatively short, all surgical procedures for establishment of airways under local anesthesia (even emergent tracheotomy) (19), necessitate a quiet and immobile patient, remaining in a supine position. Given the existing insertion site infection they also necessitate time for precision! Immobility was completely impossible for our asphyxiating patient; even a gentle pressure on neck structures during tracheostomy under local anesthesia would be unsustainable. The flexible video laryngoscopy, gave a frustrating clinical picture of a glottic closure for any medical doctor but crucially, not the underlying reason for the patient’s critical condition. The CT scan revealing a spongious cavity with gaseous content was also unreliable. Hence, the most crucial decision concerning the patient’s life, was to establish definitive airways first, and only thereafter proceeding with tracheostomy. It was undertaken at the ED from a consultant in Anesthesiology and Intensive Care. Unfortunately, there have been cases of fatalities in a similar scenario at a local hospital ED, where concerning “cannot intubate, cannot ventilate” scenario, definitive procedures for airway securing were not undertaken, but rather the patients were referred for tracheostomy under local anesthesia first. In face of severe hypoxia and rapid deteriorating of the patient with dropping level of consciousness, the anesthesia team decided to manage the upper airways by endotracheal intubation with Rapid Sequence Induction (6,7). There was no time for attempts, because strong hypnotics and muscle relaxants intubating doses administration ultimately leads to abolishment of life sustaining spontaneous breathing. In face of unsuccessful intubation, to prevent patient’s death, a last-ditch attempt would be to perform as quickly as possible one of surgical airway creation procedures, usually this, which the particular surgeon is most familiar with. Even in experienced hands, endotracheal intubation in obese and short-necked asphyxiating patient the face of a nearly total glottic closure is very risky. It necessitated skills, also rapid and profound muscle relaxation and was enabled with small 5.5 ID laryngeal tube. Only after opening a pre-tracheal fascia and coming across the unintentionally retained gauze (undoubtedly it is ubiquitous medical error) it became obvious that the long-standing neck infection leads to adduction of vocal cords and glottic closure secondary to dysfunction of laryngeal nerves and muscles. Fortunately, the patient was admitted in ED of a referral center for Head Surgery, Neck Surgery and Anesthesiology, where highly experienced staff successfully cured the patient.

Conclusions

Closed vocal cords cause severely compromized airways and require urgent intubation or tracheostomy. Airway management depends on a variety of factors, including the degree of upper airway obstruction, underlying respiratory function, and life priorities. This case is specifically described to convey the message that there can be an unanticipated and delayed airway compromize even when elective measures are undertaken against a post TT complication, which may cost a patient’s life if not immediately attended.

Acknowledgments

We are grateful to the patient GS, for agreeing to be the subject of this manuscript. By giving her consent, she is assisting in implementing practice changes when it comes to the decision making in the management of critical thyroidectomy patients.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-22-534/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-22-534/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-22-534/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. The study was approved by the Clinical Research Ethics Committee of the University Hospital “Queen Giovanna – ISUL” at the meeting on 31.08.2022 (No. CREC 2022/166).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Chahardahmasumi E, Salehidoost R, Amini M, et al. Assessment of the Early and Late Complication after Thyroidectomy. Adv Biomed Res 2019;8:14. [Crossref] [PubMed]
2. Ayandipo OO, Adigun TA, Afuwape OO, et al. Airway complications and Outcome after Thyroidectomy in Ibadan: A 15 year review. Arch Med 2016;8:7.
3. Christou N, Mathonnet M. Complications after total thyroidectomy. J Visc Surg 2013;150:249-56. [Crossref] [PubMed]
4. Sanapala A, Nagaraju M, Rao LN, et al. Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy. Anesth Essays Res 2015;9:251-3. [Crossref] [PubMed]
5. Maresch KJ. AANA Journal Course - Vocal Cord Paralysis: Implications for Anesthesia Care. AANA J 2021;89:443-8. [PubMed]
6. Ryu KA, Seo ST, Rha KS, et al. Life-Threatening Upper Airway Obstruction Caused by Delayed Hematoma Occurring 8 Days Post-Thyroidectomy. Int J Thyroidol 2015;8:187-9. [Crossref]
7. Mahmood SF, Padmanabha S, Hegde H, et al. Delayed Stridor following Thyroid Surgery: A Case Report J Evol Med Dent Sci 2014;3:7563-6.
8. Wu C, Da D, Wang J, et al. Dyspnea after thyroidectomy induced by intratracheal lymphoma: A case report. Mol Clin Oncol 2019;11:285-8. [Crossref] [PubMed]
9. González-Sánchez-Migallón E, Guillén-Paredes P, Flores-Pastor B, et al. Late tracheal perforation after total thyroidectomy. Conservative management. Cir Esp 2016;94:50-2. [PubMed]
10. Sajid B, Rekha K. Airway Management in Patients with Tracheal Compression Undergoing Thyroidectomy: A Retrospective Analysis. Anesth Essays Res 2017;11:110-6. [Crossref] [PubMed]
11. Rosenblatt WH, Abrons RO, Sukhupragarn W. Airway management. In: Barash PG, Cullen BF, Stoelting RK, et al. eds. Clinical Anesthesia. 8th ed. Lippincott Williams & Wilkins; 2017:767-808.
12. Mohtashami S, Richardson K, Forest VI, et al. Thyroidectomy for Graves' Disease Predicts Postoperative Neck Hematoma and Hypocalcemia: A North American cohort study. Ann Otol Rhinol Laryngol 2022;131:341-51. [Crossref] [PubMed]
13. Brauer PR, Burkey BB, Reddy CA, et al. Risk Assessment in Thyroid Lobectomy and Total Thyroidectomy using Over 100 Thousand Cases. Ann Otol Rhinol Laryngol 2021;130:1351-9. [Crossref] [PubMed]
14. Butler D, Oltmann S. Is Outpatient Thyroid Surgery for Everyone? Clin Med Insights Ear Nose Throat 2017;10:1179550617724428. [Crossref] [PubMed]
15. Ahmed SZ, Zafar Z, Waseem T, et al. To Drain or Not to Drain in Thyroidectomy: A Meta-analysis of Outcomes. Arch Surg Res 2020;1:6-17.
16. Shew M, Boyd C, Kraft S. Delayed Multifocal Tracheal Injury Following Thyroidectomy: A Case Report and Review of the Literature. Cureus 2020;12:e8164. [Crossref] [PubMed]
17. Shen WT, Kebebew E, Duh QY, et al. Predictors of airway complications after thyroidectomy for substernal goiter. Arch Surg 2004;139:656-9; discussion 659-60. [Crossref] [PubMed]
18. Seenarain V, Trivedi A, Flukes S, et al. Diagnosis and surgical repair of delayed tracheal perforation post thyroidectomy in context of previous cranio-spinal radiotherapy - A case report. Int J Surg Case Rep 2022;91:106761. [Crossref] [PubMed]
19. Thurnher D. Coniotomy, a Life-Saving Emergency Measure. In: Klemm E, Nowak A. editors. Tracheotomy and Airway. Cham: Springer; 2020:71-80.