Emergency Thyroidectomy in a Patient with Severe Upper Airway Obstruction Caused by Goiter: Case for Regional Anesthesia. DISCUSSION

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The occurrence of goiters causing airway obstruction is not new. As far back as 1821, Hedenus reported successful thyroidectomies in six patients for goiters, which he described as “suffocating.” Goiter still remains an uncommon cause of upper airway obstruction even today. This is particularly so in developing countries, where goiters are often neglected for long due to ignorance and lack of ready access to affordable medical services. However, when respiratory obstructive symptom does occur, it is usually insidious, intermittent and postural in manifestation, especially in bed at night, initially. Severe/life-threatening airway obstruction, as seen in our patient, is extremely rare. It is not clear why the airway obstruction in this patient suddenly worsened on admission. There was no histological evidence of hemorrhage into the thyroid gland. It could, however, be due to upper airway infection, resulting in edema and retention of secretions.

Surgery—emergency or early-is always indicated in cases of severe airway obstruction caused by goiter. However, upper airway obstruction is a medical emergency that requires urgent management. The immediate priority in this patient was to secure a patent airway to allow adequate ventilation and oxygenation. An emergency awake tracheostomy under local anesthesia was considered. This was, however, ruled out because the thyroid gland completely obscured the thyroid cartilages, obliterating all landmarks. An isthmectomy under local anesthetic infiltration followed by tracheostomy was also considered but the isthmus was involved in the large goiter. Tracheostomy carries a high risk of heavy bleeding in a patient with large goiter. An emergency debulking thyroidectomy was therefore considered the most appropriate option to relief the obstruction. Canadian healthcare viagra

Patients with compromised airway present considerable challenges to anesthetists. Many authors have emphasized the dangers of inducing general anesthesia in patients with airway obstruction, with­out prior securement of a reliable airway access. This is because unexpected and often total airway obstruction may occur when muscle tone decreases and voluntary control of airway is lost following loss of consciousness. Therefore, preservation of consciousness until the airway is secured was considered of critical importance in this patient. Consequently, in the absence of facilities for an awake fiberoptic intubation, local or regional anesthesia became the only available option to us.

Local or regional anesthesia has long been recognized as a reliable alternative to general anesthesia for thyroidectomy. Compared to local infiltration, cervical plexus block removes the need for repeated local infiltration, its attendant inconveniences to the surgeon and the patient and the possible risk of giving overdose of the local anesthetic agent. Levitra professional canada

Earlier, we had reported the successful use of bilateral superficial cervical plexus block for thyroidectomy in a series of 17 patients in our center. This technique is easier and safer than the combined superficial and deep cervical plexus block, which has been used by some other authors. Superficial cervical plexus block alone is adequate for thyroidectomy since only the superficial branches are sensory and the remainder of the cervical plexus is motor. The block provides complete sensory anesthesia of C2-C4 dermatomes, which supply the skin over the neck from the mandible to the clavicle anteriorly and laterally. This takes care of the pain of skin incision and the necessary tissue dissection involved in thyroidectomy. Beat the drug companies and buy Viagra Professional 100 mg online

The use of regional anesthesia has a number of advantages in this patient compared with any form of awake intubation technique. The technique avoided spraying the airway with local anesthetic or making contact with the vocal cords, which may be a hazardous maneuver that could precipitate total obstruction in a patient with severe stridor. Furthermore, no sedation was employed and, thus, the risk of aspiration in an unfasted patient was minimized. The patient remained conscious, retained spontaneous respiratory effort and was able to control and protect her airway. Careful tissue handling, dissection and retraction were employed to minimize the airway irritation and discomfort that may result from surgical manipulation of the thyroid gland. We could not employ our usual technique of transtracheal injection of local anesthetic to obtund the airway reactivity at the beginning of the operation in this patient because of technical difficulty due to the size of the goiter. This was, however, done as soon as the trachea was entered into before the insertion of the tracheostomy tube. An alternative method for producing anesthesia of the upper airway is to nebulize 3-4 ml of lignocaine 4% through an oxygen face mask. However, this would be unwise in an unfasted patient with a high risk of pulmonary aspiration.

Varying degrees of postural aches and pains are not uncommon during surgical procedures under regional anaesthesia. This is particularly the case in thyroidectomy because of the prolonged immobility on the hard operating table and the classical thyroidectomy position, which requires significant neck extension to guarantee optimal surgical access. The analgesic effect of the pethidine used for sedation was relied upon to relieve postural aches and pains in our patient. Adequate padding of all bony prominence was also ensured to minimize postural discomfort. Viagra canadian

The technique of combining local or regional anesthesia with sedation, as used in this patient, is known as sedoanalgesia or conscious sedation. It is a form of monitored anesthesia care, which is simple, safe and effective.

Finally, there are no universal recipes for the management of an obstructed airway. Anesthetic management of a patient with large goiter causing severe airway obstruction can be extremely challenging. We have successfully demonstrated that superficial cervical plexus block is well suited for emergency thyroidectomy in this patient. Compared to techniques that involve induction of general anesthesia, the preservation of consciousness it offered is a desirable end in itself.

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