Management of a patient with tracheomalacia and supraglottic obstruction after thyroid surgery

Abstract

Purpose We describe an unusual combination of dynamic supraglottic, glottic, subglottic, and intrathoracic airway obstructions following a total thyroidectomy. These problems were anticipated, documented videographically, and managed preemptively. Clinical features Following a total thyroidectomy, we replaced the endotracheal tube with a laryngeal mask airway, namely, the LMA-Classic TM , in a patient with symptomatic tracheal compression and probable obstructive sleep apnea. Spontaneous ventilation was observed bronchoscopically through the LMA-Classic. Supraglottic swelling, extraglottic collapse on inspiration, and intrathoracic collapse on expiration were documented prior to recovery. These observations were of sufficient concern to warrant reinsertion of the endotracheal tube and subsequent tracheal extubation over a tube exchanger. Thereafter, we provided face-mask continuous positive airway pressure using a Boussignac mask with an endotracheal ventilation catheter in situ. Conclusions Acute airway collapse following thyroid surgery is a rare and potentially serious complication. Diagnosis by conventional methods may be insensitive. Difficulties may not be apparent until the patient becomes distressed after tracheal extubation, and this circumstance will worsen airway compromise. In such a state, reestablishing the airway can become life-threatening. We describe the preemptive identification, physiologic manifestations, and management of the supraglottic and subglottic obstruction exemplified by this case. RésuméObjectif Nous de´crivons une combinaison inhabituelle d'obstructions dynamiques supraglottique, glottique, sous-glottique et intrathoracique des voies ae´riennes apre`s une thyroı¨dectomie totale. Ces proble`mes ont e´te´anticipe´s, documente´s par vide´o et pris en charge de façon pre´ventive. É léments cliniques A`la suite d'une thyroı¨dectomie totale, nous avons remplace´la sonde endotrache´ale par un masque larynge´, le LMA-Classic TM , chez un patient pre´sentant une compression trache´ale symptomatique et une apne´e obstructive du sommeil probable. La ventilation spontane´e a e´te´observe´e par bronchoscopie via le LMA-Classic. Un oede`me supraglottique, un collapsus extraglottique al 'inspiration et un collapsus intrathoracique a`l'expiration ont e´te´documente´s avant le re´veil. Ces observations e´taient suffisamment pre´occupantes pour justifier la re´insertion de la sonde endotrache´ale suivie de l'extubation trache´ale sur un e´changeur de sonde. Par la suite, nous avons mis en place une ventilation a`pression positive continue avec un masque facial de Boussignac et un cathe´ter endotrache´al de ventilation in situ.Electronic supplementary material The online version of this article (doi:10.1007/s12630-011-9570-y) contains supplementary material, which is available to authorized users.

Techniques of detecting recurrent laryngeal nerve palsy in patients undergoing thyroid surgery: Pearls and pitfalls

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