A 65-year-old woman presented at the emergency unit of the University of llorin Teaching Hospital, llorin, Nigeria, with one-week history of progressively increasing degree of breathlessness. She had a 10-year history of a progressively increasing anterior neck swelling. She had noticed a rapid increase in the size of the swelling with associated nodularity within the proceeding eight months. About two weeks prior to presentation, the patient developed a productive (purulent) cough with hemoptysis. She had no previous history of any other significant illness or anesthesia. She had no allergies. Family and social history was not contributory. Physical examination revealed a chronically ill-looking patient with dyspnea, tachypnea (respiratory rate of 32 cycles/min and stridor. She was mildly pale, afebrile, acyanosed, anicteric and not dehydrated. Her pulse was nObeats/min and regular, and blood pressure was 120/90 mmHg. She had a huge firm, nontender multinodular goiter, measuring 20×14 cm, extending from the submandibular region to the suprasternal notch (Figure 1). The goiter was more pronounced on the left. The trachea was deviated to the right with the thyroid notch located about 12 cm from the midline. She had positive Berry’s sign (left) and positive Kocher’s sign. There were cervical, supraclavicular and bilateral axillary lym-phadenopathies. The chest was clinically clear with moderate air entry bilaterally. Examinations of the other systems revealed no abnormalities. A provisional diagnosis of giant malignant goiter causing upper airway obstruction was made. The patient was admitted for investigations and scheduled for early thyroidectomy on the surgeon’s next elective list, which was to be two days later. She was commenced on oxygen therapy by nasal cannula.
Figure 1. Photograph of the patient showing goiter extending from submandibular region to suprasternal notch
Hematological and serum biochemistry results were essentially normal. X-ray of the neck (Figure 2) showed a huge multinodular goiter with retrosternal extension, producing anterior displacement of the trachea and multiple narrowing in its anteroposterior diameter. There were associated multiple amorphous and cottonwool calcifications within the goiter. Chest radiograph showed widespread cannon-ball opacities in both lung fields, (Figure 3). A diagnosis of malignant goiter, causing upper airway obstruction, with associated pulmonary metastasis was made. Need medication you can’t afford? Buy canadian pharmacy cialis
Figure 2. Neck radiograph showing goiter with retrosternal extension, tracheal displacement multiple tracheal narrowing and calcification within the thyroid gland
On the second day of admission, the patient developed severe respiratory distress. She was conscious but drowsy and restless, cyanosed, dyspneic and tachypneic (respiratory rate was 48 cycles/min). She had audible stridor with visible use of accessory respiratory muscles. Pulse was 132 beats/min, regular, bounding; and blood pressure was 100/60 mmHg. The patient felt more comfortable sleeping upright with the neck flexed. Oxygen therapy was continued and consultation sent to the anesthetist for review. The consultant ENT surgeon was also invited with a view of doing an emergency tracheostomy, but this was considered technically difficult and risky because of the size of the goiter. After consultations among the general surgeon, anesthetist and the ENT surgeon, the arrangement was made to proceed with emergency debulking thyroidectomy. Buy cheap levitra
Figure 3. Chest radiograph showing metastasis in both lung fields
Several anesthetic options were considered for thyroidectomy in this patient. Inhalational induction followed by laryngoscopy and orotracheal intubation, or blind nasal intubation, was considered too risky because of the dangers of complete airway obstruction following loss of consciousness. Rapid sequence induction and intubation were considered inappropriate in view of the possibility of a “can’t intubate/can’t ventilate” situation, and the risk of aspiration in the unfast-ed patient due to inability to apply cricoid pressure because of the huge goiter. Awake blind nasal intubation was considered but dropped in view of the distorted upper airway anatomy due to tracheal compression and deviation (Figure 2). Awake fiberoptic intubation followed by induction of general anesthesia, which others have found useful in similar situation, would have been the best option for us. Unfortunately, fiberoptic bronchoscope was not available in our hospital. This left us with the option of performing the operation under local or regional anesthesia. The anesthetic option was discussed with the surgeon and the patient was counseled appropriately.