Perioperative Management of a Large Thyroid Mass Causing Significant Tracheal Compression

32 year old previously healthy male presented to the ED with 6 months of neck swelling and 1 week of mild dyspnea while lying flat. CT scan on admission noted a large mass centered in the isthmus of the thyroid gland and... [ view full abstract ]

32 year old previously healthy male presented to the ED with 6 months of neck swelling and 1 week of mild dyspnea while lying flat. CT scan on admission noted a large mass centered in the isthmus of the thyroid gland and tracheal compression with 3-4mm airway. He was admitted to the MICU for airway monitoring. Interventional pulmonology, ENT were consulted and the patient was taken to the OR for rigid bronchoscopy with proximal stent placement and percutaneous biopsy. The patient was induced with the head of the bed elevated 45 degrees and slow induction with propofol with the goal of keeping the patient spontaneously breathing was executed. Patient tolerated induction with minimal desaturations. Rigid bronchoscopy was placed by the interventional pulmonologist and revealed severe stenosis of the proximal trachea. At the end of the case, the patient was stable for removal of the rigid bronchoscope. He was transferred to the MICU for post-operative stent management and close airway monitoring. Biopsy pathology revealed papillary thyroid carcinoma. Flexible bronchoscopy was performed in the MICU to evaluate the tracheal stent which showed tracheal stent compression.

Decision was made to take the patient to the OR for total thyroidectomy, bilateral neck dissection and central neck dissection. The patient was induced with ketamine and versed and again kept spontaneously breathing. The interventional pulmonary team remove the stent with a rigid bronchoscopy. A NIM tube was then passed through the stenotic region of the trachea. The case was complete uneventfully and the patient was eventually extubated in the MICU and discharged without complications.