The Japanese Journal of Surgery (1992) 22:88-90
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SURGERYTODAY © Springer-Verlag 1992
Upper Airway Obstruction from a Benign Goiter HIROYOSHIAYABE, KATSUNOBUKAWAHARA, YUTAKATAGAWA, and MASAO TOMITA The First Department of Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
Abstract:Acute
upper tracheal obstruction from a huge benign goiter developed in an 80-year-old woman. Computed tomography showed severe stenosis of the cervical trachea by extrinsic compression. A left hemithyroidectomy was performed and the tracheal lumen returned to normal size. However, the tracheal wall was malacic due to the prolonged compression by the goiter and a silastic T-tube insertion was necessary for a two month period. This type of tracheal obstruction is rare. The importance of evaluating the upper trachea in patients with prolonged benign goiter is stressed and the diagnosis as well as the management of this type of complication are discussed.
KeyWords:upper
airway obstruction, benign goiter, acute
resperatory failure
Introduction Large benign goiters still occur commonly in iodine deficient areas and sometimes cause upper airway obstruction. 1'2 However, this complication is uncommon in developed countries since the introduction of iodized salt. We herein report a case with sudden airway obstruction from a huge benign goiter which is rare in Japan, since Japanese have relatively high uptake of iodine.
CaseReport An 80-year-old female was referred to Nagasaki University Hospital in July 1987 because of severe dyspnea. She had a 40 year history of a huge goiter. Reprints requests to: Hiroyoshi Ayabe, MD, The First Department of Surgery, Nagasaki University School of Medicine, 7-1, Sakamoto, Nagasaki, 852, Japan (Received for publication on Aug. 31, 1990)
An asymptomatic goiter had been noted since 1947. She had experienced no respiratory problems until the beginning of July 1987. Ten days before admission, the patient had a noticed stridor, dyspnea and difficulty of expectoration. She was admitted to the Nagasaki Municipal Hospital on July 7th and underwent a flexible fiberoptic bronchoscopy. However, this was unsuccessful due to the exacerbation of dyspnea and the appearance of paroxysmal tachycardia during the procedure. A small silastic tube was then introduced percutaneously into the cervical trachea, whereby aspiration of intratracheal secretions and the administration of oxygen eventually improved her condition. Arterial blood gas values while breathing 35% oxygen were PO2 110 mmHg and PCO2 45 mmHg. Three days after the insertion of the small tracheal tube, her condition stabilized and the tube was removed without any resulting stridor or dyspnea. However, she then experienced progressive dyspnea accompanied by stridor and was transferred to our hospital three days later. An examination of the neck showed a gross, irregular and hard thyroid enlargement, which was more pronounced on the left. The left lobe was 12 × 10cm and descended below the manubrium and pushed the trachea to the right. A chest roentgenogram showed a deviated trachea with a marked narrowing and a large thyroid mass at the root of the neck (Fig. 1). Auscultation of the neck over the mass lesion revealed a bruit. Computerised tomography of the neck showed that the tracheal lumen was 90 per cent occluded and surrounded by a huge goiter with coarse calcification (Fig. 2). That evening an emergency operation was performed under general anesthesia. A collar skin incision was made in the lower neck and the thyroid isthmus was explored and divided. A left thyroid lobectomy was performed. Following the removal of the goiter the trachea returned to the center of the neck but as the wall of trachea was soft, it collapsed and a
H. Ayabe et al.: Upper Airway Obstruction from a Benign Goiter
89
Fig. 3. A microscopic examination of the resected specimen
revealed follicular adenoma. (H.E, ×200) Her postoperative course was uneventful although the T-tube insertion was necessary for 2 months after surgery. The patient trachea stabillized during the next 6 months and she is currently asymptomatic 3 years after thyroidectomy. Discussion
Fig. 1. Preoperative chest roentgenogram showing marked stenosis and a deviation of the cervical trachea and a large mass density in the lower neck. A small silastic tube was inserted into the cervical trachea percutaneously
Fig. 2. Preoperative computerized tomography of the neck showing severe stenosis of cervical trachea, which is compressed and encircled by a huge goiter. The tracheal wall is smooth
silastic T-tube was placed into the cervical trachea. A pathological examination revealed a large follicular adenoma with small loci of papillary adenocarcinoma and follicular carcinoma in the left thyroid lobe (Fig. 3).
An upper airway obstruction from a goiter usually occurs because of the intratracheal development of thyroid cancer. 3 Tracheal obstruction from a benign goiter is uncommon. 4 0 k u m a and associates 5 reported that a patient with a huge cystic goiter (1420 g) did not complain of dyspnea though his trachea was deviated and narrowed. Hata and associates 6 reported that a patient complained of dyspnea due to a huge adenomatous goiter and underwent a total thyroidectomy. This was the only previous case reported in Japan except for our case. Alfonso and associates 7 reported that 8 out of 273 patients (2.9 per cent) who underwent thyroidectomy for benign thyroid disease experienced acute respiratory distress requiring emergency treatment. Symptoms of upper airway compression from a benign goiter either develop slowly over one or two years or appear rapidly as seen in the present case. There are several causes of tracheal obstruction from a benign goiter. These include upper airway infection, 8 which leads to airway obstruction due to a swelling of tracheal mucosa and a retention of secretions, bleeding in a goiter, 9 the development of a malignant tumor, 9 or recurrence of the goiter after hemithyroidectomy.7 The risk of severe compression is greater for bilateral goiters than for unilateral nodules, since the latter can more easily escape any bony confinement. The average duration of goiter was 5.5 years before the onset of dyspneic symptoms. Our patient had a goiter for 40 years, which is longer than any previously reported
90
H. Ayabe et al.: Upper Airway Obstruction from a Benign Goiter
case. In the present ca_se, the cause of airway obstruction was considered to be upper airway infection with a retention of secretions. The small loci of cancer, observed in the resected thyroid, were not supposed to be the cause of the tracheal obstruction, because they were small in size, located in the periphery of the goiter and the increasing size of her goiter was not noticed before the ocurrence of her symptoms. In the investigation of patients with tracheal obstruction, chest roentgenogram, tomography and lateral projections are essential in order to accurately evaluate the extent, location and length of the lesions. The maximum flow volume loop is also a helpful tool in the diagnosis of upper airway obstruction and will help to distinguish it from lower airway disease, which produces similar symptoms such as dyspnea and/or wheezing. 1°'1~ In patients with a fixed tracheal obstruction, as may be produced by a goiter, the narrowed trachea limits the peak flow with inspiration and expiration. Computerized tomography is a useful test and demonstrates the extent of tracheal obstruction without discomfort to the patients.12 Fiberoptic bronchoscopy is also a helpful tool in the investigation of tracheal disease. 8-13 It reveals the extent, location and length of an obstruction. However, bleeding or mucosal edema following bronchoscopy may produce a complete airway obstruction in patients with severe tracheal stenosis. Therefore, we consider that this examination must be performed extremely carefully in patients with severe tracheal stenosis. For the same reason, tracheography with contrast material is not recommended for such patients. Chest roentgenogram should be taken to exclude the existence of obstructive pneumonitis and pulmonary disease which produce the same symptoms as tracheal obstruction. Thyroid scintigram and echography do not provide useful information in the evaluation of tracheal obstruction. The practical treatment of respiratory failure due to tracheal obstruction is to keep the airway patent. Intubation, nasal or oral, effectively alleviates dyspnea. 14 A tube of at least more than 6mm in diameter is sufficient to improve symptoms. In our patient, we introduced a small catheter percutaneously through the neck, which successfuly decreased her stridor and dyspnea after aspiration of tracheal secretions. Tracheostomy may be indicated in patients with laryngeal edema or where intubation is impossible. 15 However, tracheostomy should be performed carefully because of the high risk of heavy bleeding in some patients with a large goiter. Emergency or early operation is recommended in patients with sudden airway obstruction, because retention of tracheobronchial secretions may cause dangerous obstructive suppurative pneumonitis. The operative procedures for tracheal obstruction are either a hemithyroidectomy or total
thyroidectomy, selected on the basis of etiology and the size of goiter and the extent of tracheal obstruction. Age should not be a barrier to surgery in such patients. A trachea which has been compressed or deviated by a long-standing goiter may become malacic. Therefore, careful observation of the patient is important just after thyroidectomy. When respiratory insufficiency is recognized, the establishment of a sufficient airway is an urgent procedure. 16 Evaluating the upper trachea in patients with prolonged benign goiter is important and both the early diagnosis and treatment of upper airway obstructions are mandatory when patients complain of respiratory symptoms. Shaha 17 and associates suggested that any patient who has tracheal compression with substernal extension should also be considered for surgery.
References 1. Olurin ED (1971) Surgical Techniques in Giant Goitres. Brit J Surg 58:739-746 2. Shaha A, Alfonso A, Jaffe BM (1987) Acute airway distress due to thyroid pathology. Surgery 102:1068-1074 3. Lawson L, Som ML, Biller HF (1977) Papillary adenocarcinoma of the thyroid invading the upper air passages. Ann Otol Rhinol Larlyngol 86:751-755 4. Jauregui R, Lilker ES, Bayley A (1977) Upper Airway Obstruction in Euthyroid Goiter. JAMA 238:2163-2166 5. Okuma K, Ohyama M, Suegaga T (1972) Case report of a huge cystic go!ter. (in Japanese) Rinshogeka (J Clin Surg) 27:407-410 6. Hata H, Nishi T, Wanibuchi Y, Ohtani G, Ohara T, Flirose T, Takahashi R (1983) Case report -Tracheal obstruction due to adenomatous goiter. (in Japanese) Horumon to Rinsho (Clinical endocrinology) 31:90-92 7. Alfonso A, Christoudias G, Amarudden Q, Herbsman H, Gardner B (1981) Tracheal or esophageal compression due to benign thyroid disease. Am J Surg 142:350-354 8. Hassared AD, Holland JG (1982) Benign thyroid disease and upper airway obstruction. Case presentations, pathophysiology and management. J Otolaryngol 11:77-82 9. Torres A, Arroyo J, Kastanos N, Estopa R, Rabaseda I, Aqusti-Vadal A (1983) Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter. Crit Care Med 11:265-266 10. Canham EM, Sahn SA (1982) Recurrent "suppressed" goiter causing upper airway obstruction. Am Rev Respir Dis 125:757758 11. Warren CPW (1979) Acute respiratory failure and tracheal obstruction in the elderly with benign goiters. Can Med Ass J 121:191-194 12. Gamsu G, Webb Wr (1982) Computed tomography of the trachea: normal and abnormal. AJR 139:321-326 13. Perelman M, Kololeva N (1980) Surgery of the trachea. World J Surg 4:583-593 14. Melliere D, Saada F, Etienne G, Becquemin JP, Bonnet F (1988) Goiter with severe respiratory compromise: Evaluation and treatment. Surgery 103:367-37 15. Wade JSM (1979) Respiratory obstruction in thyroid surgery. Ann R Coll Surg 62:15-24 16. Geelhoed GW (1988) Tracheomalacia from compressing goiter: Management after thyroidecotmy. Surgery 104:1100-1108 17. Shaha AR, Burnett C, Alfonso A, Jaffe BM (1989) Goiters and Airway Problems. Am J Surg 158:378-381
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SURGERYTODAY © Springer-Verlag 1992
Upper Airway Obstruction from a Benign Goiter HIROYOSHIAYABE, KATSUNOBUKAWAHARA, YUTAKATAGAWA, and MASAO TOMITA The First Department of Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
Abstract:Acute
upper tracheal obstruction from a huge benign goiter developed in an 80-year-old woman. Computed tomography showed severe stenosis of the cervical trachea by extrinsic compression. A left hemithyroidectomy was performed and the tracheal lumen returned to normal size. However, the tracheal wall was malacic due to the prolonged compression by the goiter and a silastic T-tube insertion was necessary for a two month period. This type of tracheal obstruction is rare. The importance of evaluating the upper trachea in patients with prolonged benign goiter is stressed and the diagnosis as well as the management of this type of complication are discussed.
KeyWords:upper
airway obstruction, benign goiter, acute
resperatory failure
Introduction Large benign goiters still occur commonly in iodine deficient areas and sometimes cause upper airway obstruction. 1'2 However, this complication is uncommon in developed countries since the introduction of iodized salt. We herein report a case with sudden airway obstruction from a huge benign goiter which is rare in Japan, since Japanese have relatively high uptake of iodine.
CaseReport An 80-year-old female was referred to Nagasaki University Hospital in July 1987 because of severe dyspnea. She had a 40 year history of a huge goiter. Reprints requests to: Hiroyoshi Ayabe, MD, The First Department of Surgery, Nagasaki University School of Medicine, 7-1, Sakamoto, Nagasaki, 852, Japan (Received for publication on Aug. 31, 1990)
An asymptomatic goiter had been noted since 1947. She had experienced no respiratory problems until the beginning of July 1987. Ten days before admission, the patient had a noticed stridor, dyspnea and difficulty of expectoration. She was admitted to the Nagasaki Municipal Hospital on July 7th and underwent a flexible fiberoptic bronchoscopy. However, this was unsuccessful due to the exacerbation of dyspnea and the appearance of paroxysmal tachycardia during the procedure. A small silastic tube was then introduced percutaneously into the cervical trachea, whereby aspiration of intratracheal secretions and the administration of oxygen eventually improved her condition. Arterial blood gas values while breathing 35% oxygen were PO2 110 mmHg and PCO2 45 mmHg. Three days after the insertion of the small tracheal tube, her condition stabilized and the tube was removed without any resulting stridor or dyspnea. However, she then experienced progressive dyspnea accompanied by stridor and was transferred to our hospital three days later. An examination of the neck showed a gross, irregular and hard thyroid enlargement, which was more pronounced on the left. The left lobe was 12 × 10cm and descended below the manubrium and pushed the trachea to the right. A chest roentgenogram showed a deviated trachea with a marked narrowing and a large thyroid mass at the root of the neck (Fig. 1). Auscultation of the neck over the mass lesion revealed a bruit. Computerised tomography of the neck showed that the tracheal lumen was 90 per cent occluded and surrounded by a huge goiter with coarse calcification (Fig. 2). That evening an emergency operation was performed under general anesthesia. A collar skin incision was made in the lower neck and the thyroid isthmus was explored and divided. A left thyroid lobectomy was performed. Following the removal of the goiter the trachea returned to the center of the neck but as the wall of trachea was soft, it collapsed and a
H. Ayabe et al.: Upper Airway Obstruction from a Benign Goiter
89
Fig. 3. A microscopic examination of the resected specimen
revealed follicular adenoma. (H.E, ×200) Her postoperative course was uneventful although the T-tube insertion was necessary for 2 months after surgery. The patient trachea stabillized during the next 6 months and she is currently asymptomatic 3 years after thyroidectomy. Discussion
Fig. 1. Preoperative chest roentgenogram showing marked stenosis and a deviation of the cervical trachea and a large mass density in the lower neck. A small silastic tube was inserted into the cervical trachea percutaneously
Fig. 2. Preoperative computerized tomography of the neck showing severe stenosis of cervical trachea, which is compressed and encircled by a huge goiter. The tracheal wall is smooth
silastic T-tube was placed into the cervical trachea. A pathological examination revealed a large follicular adenoma with small loci of papillary adenocarcinoma and follicular carcinoma in the left thyroid lobe (Fig. 3).
An upper airway obstruction from a goiter usually occurs because of the intratracheal development of thyroid cancer. 3 Tracheal obstruction from a benign goiter is uncommon. 4 0 k u m a and associates 5 reported that a patient with a huge cystic goiter (1420 g) did not complain of dyspnea though his trachea was deviated and narrowed. Hata and associates 6 reported that a patient complained of dyspnea due to a huge adenomatous goiter and underwent a total thyroidectomy. This was the only previous case reported in Japan except for our case. Alfonso and associates 7 reported that 8 out of 273 patients (2.9 per cent) who underwent thyroidectomy for benign thyroid disease experienced acute respiratory distress requiring emergency treatment. Symptoms of upper airway compression from a benign goiter either develop slowly over one or two years or appear rapidly as seen in the present case. There are several causes of tracheal obstruction from a benign goiter. These include upper airway infection, 8 which leads to airway obstruction due to a swelling of tracheal mucosa and a retention of secretions, bleeding in a goiter, 9 the development of a malignant tumor, 9 or recurrence of the goiter after hemithyroidectomy.7 The risk of severe compression is greater for bilateral goiters than for unilateral nodules, since the latter can more easily escape any bony confinement. The average duration of goiter was 5.5 years before the onset of dyspneic symptoms. Our patient had a goiter for 40 years, which is longer than any previously reported
90
H. Ayabe et al.: Upper Airway Obstruction from a Benign Goiter
case. In the present ca_se, the cause of airway obstruction was considered to be upper airway infection with a retention of secretions. The small loci of cancer, observed in the resected thyroid, were not supposed to be the cause of the tracheal obstruction, because they were small in size, located in the periphery of the goiter and the increasing size of her goiter was not noticed before the ocurrence of her symptoms. In the investigation of patients with tracheal obstruction, chest roentgenogram, tomography and lateral projections are essential in order to accurately evaluate the extent, location and length of the lesions. The maximum flow volume loop is also a helpful tool in the diagnosis of upper airway obstruction and will help to distinguish it from lower airway disease, which produces similar symptoms such as dyspnea and/or wheezing. 1°'1~ In patients with a fixed tracheal obstruction, as may be produced by a goiter, the narrowed trachea limits the peak flow with inspiration and expiration. Computerized tomography is a useful test and demonstrates the extent of tracheal obstruction without discomfort to the patients.12 Fiberoptic bronchoscopy is also a helpful tool in the investigation of tracheal disease. 8-13 It reveals the extent, location and length of an obstruction. However, bleeding or mucosal edema following bronchoscopy may produce a complete airway obstruction in patients with severe tracheal stenosis. Therefore, we consider that this examination must be performed extremely carefully in patients with severe tracheal stenosis. For the same reason, tracheography with contrast material is not recommended for such patients. Chest roentgenogram should be taken to exclude the existence of obstructive pneumonitis and pulmonary disease which produce the same symptoms as tracheal obstruction. Thyroid scintigram and echography do not provide useful information in the evaluation of tracheal obstruction. The practical treatment of respiratory failure due to tracheal obstruction is to keep the airway patent. Intubation, nasal or oral, effectively alleviates dyspnea. 14 A tube of at least more than 6mm in diameter is sufficient to improve symptoms. In our patient, we introduced a small catheter percutaneously through the neck, which successfuly decreased her stridor and dyspnea after aspiration of tracheal secretions. Tracheostomy may be indicated in patients with laryngeal edema or where intubation is impossible. 15 However, tracheostomy should be performed carefully because of the high risk of heavy bleeding in some patients with a large goiter. Emergency or early operation is recommended in patients with sudden airway obstruction, because retention of tracheobronchial secretions may cause dangerous obstructive suppurative pneumonitis. The operative procedures for tracheal obstruction are either a hemithyroidectomy or total
thyroidectomy, selected on the basis of etiology and the size of goiter and the extent of tracheal obstruction. Age should not be a barrier to surgery in such patients. A trachea which has been compressed or deviated by a long-standing goiter may become malacic. Therefore, careful observation of the patient is important just after thyroidectomy. When respiratory insufficiency is recognized, the establishment of a sufficient airway is an urgent procedure. 16 Evaluating the upper trachea in patients with prolonged benign goiter is important and both the early diagnosis and treatment of upper airway obstructions are mandatory when patients complain of respiratory symptoms. Shaha 17 and associates suggested that any patient who has tracheal compression with substernal extension should also be considered for surgery.
References 1. Olurin ED (1971) Surgical Techniques in Giant Goitres. Brit J Surg 58:739-746 2. Shaha A, Alfonso A, Jaffe BM (1987) Acute airway distress due to thyroid pathology. Surgery 102:1068-1074 3. Lawson L, Som ML, Biller HF (1977) Papillary adenocarcinoma of the thyroid invading the upper air passages. Ann Otol Rhinol Larlyngol 86:751-755 4. Jauregui R, Lilker ES, Bayley A (1977) Upper Airway Obstruction in Euthyroid Goiter. JAMA 238:2163-2166 5. Okuma K, Ohyama M, Suegaga T (1972) Case report of a huge cystic go!ter. (in Japanese) Rinshogeka (J Clin Surg) 27:407-410 6. Hata H, Nishi T, Wanibuchi Y, Ohtani G, Ohara T, Flirose T, Takahashi R (1983) Case report -Tracheal obstruction due to adenomatous goiter. (in Japanese) Horumon to Rinsho (Clinical endocrinology) 31:90-92 7. Alfonso A, Christoudias G, Amarudden Q, Herbsman H, Gardner B (1981) Tracheal or esophageal compression due to benign thyroid disease. Am J Surg 142:350-354 8. Hassared AD, Holland JG (1982) Benign thyroid disease and upper airway obstruction. Case presentations, pathophysiology and management. J Otolaryngol 11:77-82 9. Torres A, Arroyo J, Kastanos N, Estopa R, Rabaseda I, Aqusti-Vadal A (1983) Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter. Crit Care Med 11:265-266 10. Canham EM, Sahn SA (1982) Recurrent "suppressed" goiter causing upper airway obstruction. Am Rev Respir Dis 125:757758 11. Warren CPW (1979) Acute respiratory failure and tracheal obstruction in the elderly with benign goiters. Can Med Ass J 121:191-194 12. Gamsu G, Webb Wr (1982) Computed tomography of the trachea: normal and abnormal. AJR 139:321-326 13. Perelman M, Kololeva N (1980) Surgery of the trachea. World J Surg 4:583-593 14. Melliere D, Saada F, Etienne G, Becquemin JP, Bonnet F (1988) Goiter with severe respiratory compromise: Evaluation and treatment. Surgery 103:367-37 15. Wade JSM (1979) Respiratory obstruction in thyroid surgery. Ann R Coll Surg 62:15-24 16. Geelhoed GW (1988) Tracheomalacia from compressing goiter: Management after thyroidecotmy. Surgery 104:1100-1108 17. Shaha AR, Burnett C, Alfonso A, Jaffe BM (1989) Goiters and Airway Problems. Am J Surg 158:378-381
