AIRWAY MANAGEMENT IN LARGE ANAPLASTIC THYROID CARCINOMA.
Objective: To demonstrate use of nasotracheal intubation in airway management of large anaplastic thyroid carcinoma.
Study Design: Descriptive case series.
Place and Duration of Study: Combined Military Hospital Lahore, from January 2014 to May 2015
Material and Methods: Respiratory compromise in five cases of an a plastic thyroid carcinoma were managed by nasotracheal intubation. Following intubation a planned tracheostomy was carried out. Airway was secured using a modified tracheostomy tube.
Result: Of the five cases in this descriptive case series, 2 (40%) were females and 3(60%) were males. Airway in all patients were managed with nasotracheal intubation and modified tracheostomy tube.
Conclusion: Management of large anaplastic carcinoma requires some modifications in terms of intubation and tracheostomy.
Keywords: Anaplastic Thyroid Carcinoma, Nasotracheal, Tracheostomy.
Malignant thyroid masses account for 5% of all thyroid masses. With a variety of histological patterns, airway involvement occurs in nearly all the types in latter stages1. Extra thyroidal extension is not commonly seen and represent about 6 - 13% of cases of thyroid malignancies. Extrathyroidal invasions most commonly affect strap muscles, recurrent laryngeal nerves, trachea, esophagus and neck vessels2.
Undifferentiated malignant thyroid carcinomas are prone to invade the trachea and surrounding structures early. Among them, anaplastic carcinoma is the rarest and spreads rapidly. Incidence of anaplastic thyroid carcinoma reported in western literature is 0.21 per 100,000 (pacini)3. Aggressive nature of this carcinoma is well documented and mean survival time in literature is quoted to be 6 months. The main cause of death is involvement of surronding structures resulting in life threatening complications. It is relatively uncommon to see large thyroid masses with respiratory distress. Malignant thyroid masses with size larger than 10 centimeters tend to cause airway obstruction by mechanical compression of trachea and also by tracheal invasion. Respiratory distress in such cases is often fatal and gives limited time to establish an airway4.
Management of such cases becomes a challenge due to various reasons: 1. Inability to intubate the patient due to distortion of laryngeal inlet by mass effect, 2. Awake tracheostomy results in desaturation and respiratory distress5, 3. Increased vascularity of thyroid can cause potentially life threatening bleeding, 4. Conventional tracheostomy tubes cannot be used as there length is not sufficient to deal with massively enlarged thyroid masses. Therefore an improvised tracheostomy tube was used to achieve adequate length to canulate the trachea6.
MATERIAL AND METHODS
This is a case series review of five patients of large anaplastic thyroid carcinoma managed by ENT department CMH Lahore from October 2013 to September 2015. Sampling technique was "Purposive sampling". All five patients were brought in stridor and were subsequently managed in main operation theater. Help of preoperative computerized tomography of neck was taken to generate a road map of the deviated trachea. Awake fiber optic nasoendoscopy was done in a sitting position as the patients were unable to lie down. Upon visualization of vocal cords patients were intubated via nasal route using an endotracheal tube number 5.5. Using the CT scan, trachea was traced and an opening in the trachea made. An improvised tracheostomy tube was placed in each case. Improvised tracheostomy tube was created by dividing a No.7.5 endotracheal tube above the exit of cuff channel.
A No. 5 tracheostomy tube was divided with a 1.5 cm stump. The tracheostomy tube stump was fixed in the endotracheal tube and the junction secured with silk suture as shown in figure 1. Improvised tracheostomy tube was fixed to neck with silk sutures (size Number 1).
All data was analyzed using SPSS (version 13.0). Frequency and percentage was calculated for gender. Mean +- SD was calculated for quantitative variables like age.
Patient was a 65 year old male diagnosed as a case of Anaplastic carcinoma thyroid three weeks prior to tracheostomy. The thyroid mass measured 15 / 9 cm in the largest dimension which had pushed the trachea to left. Patient had presented in emergency with increasing stridor. (fig-2).
Patient was a 57 year old male diagnosed as Anaplastic carcinoma thyroid. The thyroid mass was measured 16.8 / 10.3 cm in the largest dimension and had pushed the trachea to right. Patient was counseled previously for tracheostomy but had refused. He subsequently presented in a cyanosed state with severe stridor.
Patient was 22 year old female diagnosed as a case of Anaplastic cell carcinoma thyroid. The thyroid mass was 18 / 12 cm in largest dimension and trachea was compressed and being deviated to right.
Patient was 47 year old male diagnosed as a case of Anaplastic cell carcinoma thyroid. The thyroid mass was 11.2 / 9.4 cm in largest dimension and trachea was compressed and was in midline. The presenting complaints were severe respiratory distress.
Patient was 61 year old female diagnosed as a case of anaplastic cell carcinoma thyroid. The thyroid mass was 13.4 / 11 cm in largest dimension and trachea was compressed and being deviated to right. She presentation with respiratory distress.
The study group comprised of 5 patients, 2 (40%) females and 3 (60%) males. Mean age was 47.7 years SD 18.6. Mean time from diagnosis to respiratory distress was 22 days. Post operatively patients were managed by ventilatory support for at least 24 hours. All the patients were subsequently able to maintain 100% oxygen saturation without oxygen support. Regular tracheostomy care was ensured.
Anaplastic thyroid carcinoma is documented as one of the most rapid growing malignant tumors with a median overall survival of 6 months or less7. This tumour accounts for fewer than 5% of all thyroid malignancies but it is responsible for up to 90% of thyroid cancer deaths8. Typical presentation is of a rapidly enlarging aggressive mass complicated by symptoms like stridor, dysphagia, vocal cord paralysis, neck pain and dyspnea due to rapid extra thyroidal spread9. In up to half of the cases of anaplastic thyroid carcinoma there is evidence of distant metastatic disease at time of initial diagnosis10, and the most common sites being spine, lungs, and brain. Regardless of treatment ensued nearly all literature available on anaplastic thyroid carcinoma shows that majority of the cases develop distant metastases during treatment11.
Regarding surgical treatment anaplastic thyroid carcinoma, surgical clearance is usually not possible due to its invasive nature. Surgical treatment is usually aimed at relief of airway obstruction secondary to mass effect of enlarged thyroid. Radical surgical treatment like total thyroidectomy and radical neck dissection gives no added advantage over less radical surgical treatment or non surgical treatment12 . This is due to the fact that extra thyroidal spread cannot be controlled and incision site infection is very common. Total thyroidectomy can be carried out if cervical and mediastinal disease can be surgically removed. In most of the cases, debulking of the tumor is considered to be an adequate treatment option. Literature research shows that complete thyroid resection is mostly associated with longer survival than debulking alone. Local regional control of disease is an important consideration in management of anaplastic thyroid carcinoma13.
Management of respiratory distress is by tracheostomy alone. Emergency awake tracheostomy can be used to secure an airway in patients with life threatening airway obstruction. But emergency awake tracheostomy is riddled with complications, of which the most dreaded are uncontrolled haemorrhage, airway compromise, pn-eumothorax and nerve damage. Fiberoptic naso tracheal intubation secures the airway and helps in creation of tracheostomy stoma. By passing endotracheal tube, respiratory distress is controlled and tracheostomy becomes a controlled elective procedure14. Furthermore, we have incorporated a technique of improvised tracheostomy tube which gives extra length so as to accomodate for bulk of the tumour in neck.
Management of respiratory distress in malignant thyroid carcinoma is greatly helped by radiological studies. Patients with large tumors or signs or symptoms suggestive of invasive disease warrant further radiographic evaluation15. The most helpful radiological investigation is computerized tomogram with contrast. Position of trachea can be adequately ascertained and incision can be planned accordingly. Three dimensional reconstruction on computerized tomography can give a realistic road map with exact tract of trachea, and information about tissue covering trachea and tracheal invasion16.
Airway control in large thyroid masses is best achieved by endoscopic guided nasotracheal intubation, followed by planned tracheostomy using an improvised tracheostomy tube.
CONFLICT OF INTEREST
The authors of this study reported no conflict of interest.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Feb 29, 2016|
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