Asian Cardiovasc Thorac Ann 2006;14:416-417
© 2006 Asia Publishing EXchange Ltd
Multinodular Goiter Compressing the Trachea Following Open Heart Surgery
Lokeswara R Sajja, MCh,
Gopi C Mannam, FRCS,
Sriramulu Sompalli, MD1,
Chandra SR Simhadri, MCh2,
Ashfaq Hasan, MD3
Division of Cardiothoracic Surgery
1 Division of Cardiac Anesthesiology
2 Division of Surgical Oncology
3 Division of Pulmonology, Care Hospital, Institute of Medical Sciences, Hyderabad, India
For reprint information contact: Gopi C Mannam, FRCS Tel: 91 40 5566 1935 Fax: 91 40 5562 5003 Email: gmannam{at}yahoo.com, Division of Cardiothoracic Surgery, Care Hospital, The Institute of Medical Sciences, Road No. 1, Banjara Hills, Hyderabad 500 034, Andhra Pradesh, India.
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ABSTRACT
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Acute hemorrhage into an adenomatous goiter following cardiac surgery is a rare cause of acute upper airway obstruction. We report an unusual presentation of respiratory distress in a patient with goiter recovering from open heart surgery, which was successfully treated by left hemithyroidectomy. A mandatory evaluation of the upper trachea in patients with long-standing benign goiter is recommended prior to cardiac surgery.
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INTRODUCTION
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Approximately 4% of the adult population has clinically palpable thyroid nodules, with prevalence increasing in the later decades of life1 and women being affected more often than men. The growth is an uncommon source of postoperative complication of cardiac surgery. Consequently, hemorrhage into an adenomatous goiter is not often diagnosed and optimal therapy has not been established. Here we report an unusual presentation of hemorrhage into an adenomatous goiter involving the isthmus, subsequently causing respiratory distress in a patient who had undergone elective valve replacement. The condition was treated by left hemithyroidectomy.
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CASE REPORT
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A 60-year-old diabetic lady with a history of exertional breathlessness of New York Heart Association functional class II was diagnosed with a severely stenosed, calcified bicuspid aortic valve with a peak systolic gradient of 104 mm Hg. Physical examination revealed that she had a moderate-sized thyroid swelling with multiple nodules but was clinically euthyroid. There had been no recent change in the size of the goiter. Examination of the cardiovascular system revealed physical signs that were consistent with severe aortic stenosis. Her thyroid function tests were normal with a total thyroxine level of 8.7 µg·dL–1, total triiodothyronine of 60 ng·dL–1, and thyroid stimulating hormone of 0.2 mIU·mL–1. Spirometric evaluation showed evidence of fixed airway obstruction suggesting extrinsic compression of the trachea by the goiter, as well as significant post-bronchodilator reversibility in airflow obstruction in both small and large airways implying the co-existence of allergic airway disease. Her complete blood picture and kidney function were normal.
Elective aortic valve replacement with a Medtronic Hall prosthetic valve (Medtronic, Inc., Minneapolis, MN, USA) was performed under general anesthesia and cardiopulmonary bypass (CPB), with an aortic crossclamp time of 75 minutes and total CPB time of 100 minutes. Endotracheal intubation was established without difficulty. The patient was weaned off CPB easily. She was ventilated electively for 6 hours and then extubated. Two hours later, her breathing became labored and her arterial carbon dioxide tension rose while arterial oxygen tension remained at a satisfactory level. She became drowsy and had to be reintubated for mechanical ventilation. Intravenous steroid (hydrocortisone) was administered to reduce any inflammatory edema of the vocal cords. The patient was gradually weaned off the ventilator after 24 hours and extubated. A few hours later, she again developed respiratory distress with a carbon dioxide tension of 70 mm Hg and became drowsy. Fiberoptic bronchoscopy showed subglottic extrinsic anteroposterior compression of the trachea and normal vocal cords. She was reintubated and ventilated. The next day, the thyroid swelling was evaluated by ultrasonography, which showed diffuse enlargement of the thyroid with multiple mixed-echoic space-occupying lesions. She underwent left hemithyroidectomy on the 4th day after the initial operation and was ventilated electively for 24 hours following surgery. She made a steady recovery with no further episodes of respiratory distress and was discharged 6 days later. A cut section of the resected specimen showed hemorrhage in the isthmus of the thyroid (Figure 1
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DISCUSSION
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Large goiters with intrathoracic extension may compress the trachea and cause respiratory distress.2 Although hemorrhage and infarction of pituitary adenomas associated with cardiac surgery have been documented,3 their occurrence in thyroid adenomas has not been reported. Infarction and/or hemorrhage of the adenoma could be attributed to the use of CPB, because of increased susceptibility of the abnormal adenomatous tissue to ischemia or hypoperfusion and increased tendency of the fragile vasculature of the adenoma to bleed as a result of heparinization prior to the institution of CPB, as has been observed in pituitary adenomas.3 Sudden enlargement of the thyroid following acute hemorrhage into an adenoma may lead to extrinsic compression of the trachea.
Our patient was euthyroid with a goiter that clinically appeared moderate in size. Although on spirometry the flow volume loops showed fixed obstruction, we presumed that this thyroid swelling would not pose any problem to the performance of cardiac surgery and to postoperative recovery. However, abnormal upper airway dynamics are increasingly recognized in patients with goiter.4 When recurrent respiratory distress occurs in a patient with pre-existing goiter recovering from open heart surgery, extrinsic compression of the cervical trachea due to hemorrhage into the goiter should be suspected and, if confirmed, can be effectively managed by hemithyroidectomy.5 Emergency thyroidectomy to relieve severe obstruction has also been recommended.6 Relieving airway obstruction is mandatory in all intubated patients with such a condition to avoid prolonged mechanical ventilation. Relief of the obstruction following excision can be demonstrated by normalization of the flow volume loops.
A mandatory evaluation of the upper trachea is recommended in patients with long-standing benign goiter undergoing open heart surgery in order to avoid postoperative complications. After ruling out any other cause of stridor and establishing the diagnosis of hemorrhage into the goiter using ultrasonography and bronchoscopic evidence of extrinsic compression of the trachea, emergency hemithyroidectomy can be performed to rapidly and effectively release the compression and relieve respiratory distress.
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REFERENCES
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- Thomas CG. Nodular goiter and benign and malignant neoplasms of the thyroid. In: Sabiston DC Jr, editor. Davis-Christopher textbook of surgery. 12th ed. Philadelphia: Saunders, 1981;690–713.
- Raftos JR, Ethell AT. Goitre causing acute respiratory arrest. Aust N Z J Surg 1996;66:331–2.[Medline]
- Pliam MB, Cohen M, Cheng L, Spaenle M, Bronstein MH, Atkin TW. Pituitary adenomas complicating cardiac surgery: summary and review of 11 cases. J Card Surg 1995;10:125–32.[Medline]
- Thusoo TK, Gupta U, Kochhar K, Hira HS. Upper airway obstruction in patients with goiter studies by flow volume loops and effect of thyroidectomy. World J Surg 2000;24:1570–2.[Medline]
- Ayabe H, Kawahara K, Tagawa Y, Tomita M. Upper airway obstruction from a benign goiter. Surg Today 1992;22:88–90.[Medline]
- Lim RY. Emergency thyroidectomy for tracheal obstruction. W V Med J 1983;79:75–7.[Medline]
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ABSTRACT
INTRODUCTION
