|Year : 2015 | Volume
| Issue : 1 | Page : 144-147
Anesthetic management of carcinoma of thyroid involving trachea in a patient with hypertrophic obstructive cardiomyopathy
Sapna A Nikhar, Monu Yadav, Ramachandran Gopinath, Mohammad Azharuddin
Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
|Date of Submission||10-Sep-2014|
|Date of Acceptance||15-Jan-2015|
|Date of Web Publication||25-Mar-2015|
Department of Anaesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Telangana
Source of Support: None, Conflict of Interest: None
Airway management still remains a challenge for anesthesiologists. We discuss a case of carcinoma of thyroid infiltrating trachea, causing respiratory distress in a patient with hypertrophic obstructive cardiomyopathy. This presentation is itself a challenge to the anesthesiologists in view of difficult airway. Hypertrophic obstructive cardiomyopathy can worsen the condition. To avoid and manage any complications, we need to anticipate the course of surgery and design a successful anesthetic plan.
Keywords: airway management, hypertrophic obstructive cardiomyopathy, thyroid cancer
|How to cite this article:|
Nikhar SA, Yadav M, Gopinath R, Azharuddin M. Anesthetic management of carcinoma of thyroid involving trachea in a patient with hypertrophic obstructive cardiomyopathy. Ain-Shams J Anaesthesiol 2015;8:144-7
|How to cite this URL:|
Nikhar SA, Yadav M, Gopinath R, Azharuddin M. Anesthetic management of carcinoma of thyroid involving trachea in a patient with hypertrophic obstructive cardiomyopathy. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2020 Apr 1];8:144-7. Available from: http://www.asja.eg.net/text.asp?2015/8/1/144/153958
| Introduction|| |
Hypertrophic obstructive cardiomyopathy (HOCM) is a complex cardiac disorder with myocardial hypertrophy, leading to left ventricular outflow tract obstruction  . Patients can be asymptomatic, can have minor rhythm disturbances or can land up in sudden death  . Management of HOCM case in itself requires very specific considerations as per anesthetic plan is concerned. Patients with associated difficult airway may further complicate the situation. Anesthetic management requires maintenance of desired hemodynamic, fluid management, and also active management of specific complications. Left ventricular outlet obstruction can be further exacerbated by tachycardia, hypovolemia, vasodilatation, and increased cardiac contractility. Hence, carcinoma of thyroid infiltrating trachea in patients with HOCM is a unique challenge to the anesthesiologists. Any intraoperative problem can worsen the situation, increasing morbidity and mortality.
| Case report|| |
A 55-year-old female patient underwent total thyroidectomy for carcinoma thyroid infiltrating the trachea. The patient was admitted to the hospital with complaints of swelling in midline of the neck, along with change in voice and difficulty in breathing for the last 3 months, with exacerbation of symptoms for the last 10 days. She was examined and investigated by surgical colleagues. The routine laboratory investigations and thyroid function tests were within normal limits. On cardiac evaluation, ECG showed left axis deviation with left ventricular hypertrophy. Two-dimensional echocardiography showed HOCM with a gradient of 44 mmHg, the presence of left ventricular hypertrophy, no valvular pathology, and regional wall motion abnormality with good left ventricular function. A neck radiograph ([Figure 1]) and computed tomography of the neck ([Figure 2]) showed gross narrowing of 2-3 mm of lumen of the trachea.
She was a known hypertensive since 5 years on amlodipine 5 mg once daily. She had undergone transurethral resection of bladder tumor for carcinoma of bladder under subarachnoid block 1 year back; postoperative cystoscopy was normal. No cardiac evaluation was carried out at that time. There was no history suggestive of hypothyroidism or hyperthyroidism. The patient was prescribed atenolol 50 mg once daily for 1 week, and nebulization with bronchodilators was started for respiratory optimization. The patient was indicated for surgery after control of pulse rate to 70/min or less.
On preanesthetic evaluation, the patient had a pulse rate of 54/min, blood pressure (BP) of 160/90 mmHg, and oxygen saturation of 99% on room air. Airway examination showed Mallampati grade II with short neck, but neck extension was normal. As per findings of airway examination and gross narrowing of the trachea in computed tomography and radiography of the neck, airway difficulty was anticipated. The patient and relatives were explained about difficult airway and associated high risk, along with the need for tracheostomy if required, and informed consent was obtained.
Awake fiberoptic intubation was planned, and backup for emergency tracheostomy was arranged. A difficult airway kit was arranged and emergency drugs were kept ready. After explaining the procedure to the patient, venous access was secured. Topicalization of the upper airway was carried out with lidocaine spray 4%; for the lower airway, lidocaine nebulization was carried out. Under local infiltration, intra-arterial cannula was placed in the left radial artery for invasive BP monitoring. Peripherally inserted central venous catheter was placed through the right basilic vein. Preoxygenation with a face mask was started. Dexmedetomidine infusion was given at a loading dose of 1 μg/kg intravenously over 10 min, followed by a continuous infusion of 0.5 μg/kg/h. The patient was continuously monitored for heart rate, ECG, invasive BP, central venous pressure, SpO 2 , and end-tidal CO 2 .
Injection Esmolol 10 mg boluses were used to control BP if BP was more than 140/90 mmHg. Propofol was administered at incremental doses of 0.25 mg/kg intravenously. The patient was well sedated, hemodynamicaly stable, and maintained regular spontaneous respiration with adequate tidal volume. Fiberoptic broncoscopy was attempted. On advancement of bronchoscope into the trachea, she suddenly developed severe laryngospasm and jaw rigidity, and SpO 2 fell to 80%. Continuous positive airway pressure (CPAP) and intermittent positive pressure ventilation with mask failed to raise saturation. Injection Propofol 50 mg iv was administered slowly, along with titrated inhalational sevoflurane, still ventilation was not possible. CPAP was continued to maintain SpO 2 , which was continuously dropping and reached to 50%. In view of severe laryngospasm and inability to maintain saturation with CPAP and intermittent positive pressure ventilation with mask, 50 mg bolus of succinylcholine intravenously was administered, direct laryngoscopy was performed, and intubation was attempted. Endotracheal tube of 6.5 mm internal diameter was placed with bilateral equal air entry. Saturation reached 100% and rest of the vitals were stable. Ryle's tube was placed. Anesthesia was maintained with O 2 : air (1: 1) and isoflurane mixture (0.5 minimum alveolar concentration), with controlled ventilation as routine practice. Dexmedetomidine infusion was continued intraoperatively until surgeons started with closure. An injection of vecuronium 1 mg intermittent boluses were administered to maintain muscle relaxation whenever required.
Surgery was started, and after exposure of the trachea, tracheostomy was performed. Along with thyroid, cricoid cartilage and two tracheal rings were resected. There was minimal blood loss, and all arterial blood gas parameters were maintained. After completion of the procedure, muscle relaxation was reversed. After adequate recovery, she was shifted to postoperative ICU with tracheostomy tube in situ on T-piece for close monitoring of vitals. The postoperative period was uneventful. The patient was discharged with permanent tracheostomy 6 days after the procedure.
| Discussion|| |
Patients with carcinoma thyroid infiltrating the trachea may have a distorted tracheal lumen due to external compression by tumor, intraluminal growth of tumor, and paralyzed vocal cords. Preoperative review of cervical spine imaging by anesthesiologist, along with the surgical colleague, is essential to frame a successful anesthetic and surgical plan. They are also prone to hemorrhage, which can further worsen airway distress. Fiberoptic intubation using a flexible bronchoscope with topical anesthesia is appropriate in selected cases. A small-diameter, lubricated endotracheal tube facilitates intubation past potential points of tracheal obstruction, compression, or narrowing. Tracheostomy is avoided  if possible, because this leads to surgical bed contamination with tracheal secretions, complicates the surgical wound, and delays postoperative wound healing if tracheal repair is required after tracheal sharing.
In practice,  majority of the patients' induction can be performed with inhalational or intravenous agents by means of airway maintenance using a face mask, followed by bronchoscopy and intubation. In these patients, preservation of spontaneous breathing was found to be useful  . For this patient also we tried to maintain spontaneous respiration, but as the patient was already in stridor, she developed desaturation during bronchoscopy, with severe laryngospasm. Because of failure to maintain saturation with CPAP and positive pressure ventilation, short acting muscle relaxant was administered and direct intubation was performed.
This type of presentation and airway difficulty can precipitate cardiac events, with a high probability in patients with pre-existing cardiac disease. HOCM is a most common genetic cardiovascular disease characterized by dynamic left ventricular outflow tract obstruction  . Clinical presentation may vary from asymptomatic to various rhythm disturbances and/or sudden cardiac death. Most of the patients with unrecognized HOCM may have sudden and unexpected systemic hypotension or other multiple precipitating factors, which may trigger dynamic left ventricular outflow tract obstruction  . Factors such as tachycardia, hypovolemia, vasodilation, and increased cardiac contractility exacerbate the obstruction  . Particularly relevant to the operating room and perioperative care, dynamic outflow tract obstruction in HOCM can occur acutely and unexpectedly, provoked or accentuated, by conditions that increase myocardial contractility (e.g. tachycardia and stress), or decrease preload and ventricular volume (e.g. vasodilators, hypovolemia, and hypotension)  . Failure to ventilate itself can precipitate dynamic obstruction by aggravating above mentioned conditions plus hypoxia, and hypercarbia being additive factors.
Anesthetic management entails maintenance of desired hemodynamic parameters and management of specific complications such as hypotension, dysrhythmias, and congestive heart failure , . Proper hydration and drugs that mildly depress myocardial contractility and reduce oxygen demand, maintaining intravascular fluid volume and systemic vascular resistance, are the mainstay in avoiding provocation of left ventricular outflow tract obstruction. To avoid tachycardia and precipitate dynamic obstruction, this patient was started on β-blockers.
With same target, we used dexmedetomidine. Dexmedetomidine has sedative, analgesic, sympatholytic, and anxiolytic effects that blunt many of the cardiovascular responses during the perioperative period. It reduces the requirements for volatile anesthetics, sedatives, and analgesics without causing significant respiratory depression  . It was associated with less delirium, tachycardia, and hypotension, but more bradycardia  . Dexmedetomidine helped us to maintain desired hemodynamics. No major changes in hemodynamics were observed, and the procedure was completed within 2 h without major fluid shifts.
| Conclusion|| |
Carcinoma of thyroid with tracheal involvement causing narrow tracheal lumen is a real challenge. We need to plan a proper anesthetic technique to prepare our mind to face any difficult situation and immediate steps to manage them to prevent morbidity and mortality. Cardiac conditions such as HOCM adds to challenge, and we need to understand the proper pathophysiology of the condition to avoid further complications.
| Acknowledgements|| |
Conflicts of interest
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[Figure 1], [Figure 2]