THYROID CASE PRESENTATION

• A 65 years old female patient by name seshachalam konda housewife from sattenapalli came with a chief complaint of swelling infront of the neck since 4 months.

• Neck pain associate with head ache since 4 months

• H/O present illness: • The present complaint started as small

swelling 4 months back infront of the neck initially on the right side, which is insidious in onset and gradually progressed to obtain the present size.

• No H/O sudden increase in size of the swelling • No H/O of difficulty breathing , difficulty in swallowing and

hoarsness of voice or stridor• No H/O weight gain✔ H/O decreased sleep since 4 months

• No H/O hair loss• No H/O intolerance to cold or heat.✔ H/O constipation since 6 months.

• No H/O excessive sweating.• No H/O excessive fatigue/ genaralised weakness.• No H/O irritability, tremor and palpitation.• No H/O diplopia & visual diaturbance• No H/O dyspnea on excertion, chestpain.• No H/O loss of consciousness or syncope.• No H/O swelling feet.

• Past history:• No H/O similar complaints in the past• Not a known hypertensive or diabetic • No H/O brochaial asthma, TB, epilepsy,

jaundice.• No H/O previous surgeries, on blood

transfusions.• No H/O allergy to known medications.

• Personal history:• Takes mixed diet• Appetite – normal• Sleep decreased : 4 months• Treatment history:• No treatment H/O for thyroid• Family history• No H/O similar complaints in any of

the family members.

• Menstrual history:• Attained menarche at the age of 13 years.• Married.3 children• Now she attained menopause 16

yearsback.• Past cycles were regular 3/30 - mod flow.

• General Examination:• Patient is conscious and coherent, co-operative,

attentive and answering the questions immediately.

• Moderately built and nourished• weight- 62 kgs• height 158cms.• Facies – normal• Skin – normal• Nails – normal• No pallor, icterus, cyanosis, Clubbing & pedal

oedema.

• No tremors of hand or tongue.• No excessive sweating, excitability.• Eyes – normal.no chemosis( swelling/

oedema of conjunctiva)• Deep tendon reflexes – normal

• Vitals:• Patient is afebrile• PR- 82b/min. regular, normal volume ,no special

characters n,o vessel wall thickering ,• No radio – radial or Radio – femoral delay• All peripheral pulses are felt equally on both sides • BP- 130/80 mmhg in right arm in supine position.• 130/ 80 mmhg in left arm in supine position.• Respiration – 14 breath/mt– regularThoraco –

abdominal pattern

• Airway assessment:• Malmapatti grading II• Spine – normal• Neck extension – normal• Mouth-opering – adequate(3 finger

breadth).• no loose tooth.

• Local Examination of Thyroid Swelling :• Inspection:• A single nodular swelling is noted on the right side infront of lower

part of the neck.• Surface - appearance to be smooth• Extension – superiorty – 5cm from the mandible.• Inferiorly – 2.5 cm from the medial end of clavicle• Laterally- extended over the SCM of right side• Trachea is shifted towars left• Pembertoris sign is negave• The swelling is moving up with degultation • Not moving with protrusion of tongue lower border of swelling can be

seen• No visible veins/ engorged veins.• No visible pulsation and the swelling is not pulsatile.• No scars or sinus over the swelling • Skin over the swelling is normal..

• Palpitation: on palpitation• No local rise of temperature.• Inspectory findings are confirmed.• Trachea deviated towards left side• A single large swelling of size 8 x 5 cm in front of the lower part of

neck extended:• Superior 5 cm from mandible• Inferior 2.5 cm above the medial end of clavicle• Laterally: extends upto SCM of the right side• Swelling in moving up with degultation not moving up with

protrusion of tongue.• Lower border of the swelling is felt getting below the swelling is

possible.

• Surface is smooth, soft in consistency.• Swelling is mobile, in horizontal direction.• Fluctuation is negative swelling is not reducible or compressible.• There are no pulsations over the swelling & swelling itself is

non-pulsatile.• The swelling Is not fixed to the surrounding structures.• Bilateral carotid pulsation felt.• No cervical lymphadenopathy.• Percussion:• Resonant note is heard over the manubarium sterni • Auscultation:• No bruit over the swelling.

• Systemic examination:

• CVS: 1st & 2nd, H.S are heard, no murmers, no bruit, JVP normal.

• CNS: • Higher mental functions – normal• Tone – normal• Power – 5/5 in all limbs.• Sensory system examination Normal

• Respiratory system:• B/L air entry present• Normal vesicular breath sounds are heard (equal on both sides)• No adventitious sounds

• GIT-- per abdomen- soft• liver & spleen not palpable.• Bowels sounds heard.

• Ophthalmic Examination:• Pupils:normal in size,Reaction to light present.• Vision is normal.• No exopthalmus.• No specific eye signs.

• Provisional Diagnosis:• A 55 years old female patient with solitary

thyroid swelling posted for subtotal thyroidectomy.

Examination for toxic manifestation

1. Exophthalmos :

In early stages, may be unilateral but later may become bilateral.

• Stellwag's sign : Infrequent blinking of eyes with widening of palpabral fissure.

• Von Graefe`s sign : Upper eye lid lags behind the eye ball as the patient is asked to look downwards.

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• Dalrymple's sign : Upper sclera is visible due to retraction of upper eye lid.

• Joffroy's sign : Absence wrinkling in the forehead on looking upwards with the face inclined downwards.

• Moebius sign : Inability or failure to converge the eye balls

• Gifford's sign: Difficulty in eversion of the upper lid.

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Pre operative preparation • Admission

• Absolute bed rest.

• Sedation Diazepam 2mg-5mg.

• Β blockers, e.g propranolol 40mg 1-1-1

• Specific drugs, e.g Carbimazole 5mg 1 qid & then slowly reduced to 1 bd. Given for 4-6wks. 24

• Resting pulse chart.

• Thyroid function tests should be done every 4wks till EUTHYROID STATE

• Patient must be made euthyroid or near euthyroid at operation.

• Euthyroid is clinically assessed by-

– Sleeping pulse rate < 90/min– Relief of toxic symptoms– Progressive weight gain– Improvement of ECG– Return of serum levels of thyroid hormones to normal

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• ENT check-up for mobility of cords.

• The last dose of ATD may be given on the evening before surgery.

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Plan of Anaesthesia

• General anesthesia.

• Regional – Cervical Epidural Anesthesia.

• Local blocks- Cervical plexus block (b/l)

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GENERAL ANAESTHESIA Premedication :

• Aim is to suppress sympathetic activity.

• Diazepam /Lorazepam.

• Anti aspiration prophylaxis.

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Monitoring :

• Pulse oximetry• NIBP• ECG• Temperature monitoring• ETCO2• Neuromuscular monitoring• CVP line• Urine output

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• Wide bore IV line is secured.

1. Pre-oxygenation : With 100% 02 for 3-5 minutes.

2. Induction.• Inj. Thiopentone sodium 5-7mg/kg i.v is the

drug of choice.• Inj. Glycopyrolate- 0.0l mg/kg i.v

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• Attenuation of sympathetic response to intubation by Inj. Lignocaine 1.5-2mg/kg i.v or Opioid/ Esmolol infusion can be used.

3. Intubation• Inj Scoline 2mg/kg if difficult airway

anticipated.

• Inj Vecuronium 0.08-0.12 mg/kg iv or Inj. Rocuronium 0.5mg/kg iv if easy airway anticipated

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When airway problem is anticipated

• Awake/fibreoptic intubation can be done with local anaesthesia.

• Intubation with gentle laryngoscopy is done with cuffed armored tube/ cuffed ETT/north pole oral tracheal tube or intubating LMA with fiber optic bronchoscopy guidance.

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• Patient is positioned with sand bag between the shoulder blades and the head resting on a padded horse shoe.

• Avoid hyperextension.

• Arms should be secured by the side with the ulnar nerves padded and protected.

• Special care to protect the eyes from injury in patients with exophthalmos.

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4. Maintenance of Anaesthesia :

• Controlled ventilation is used with N20 + 02 + NDMR + inhalation agents + incremental doses of opioids.

NDMR :• Inj. Vecuronium 0.05 mg/kg or • Ini. Atracurium 0.3 - 0.4 mg/kg or • Inj. Rocuronium 0.3 - 0.4 mg/kg. 34

• Already existing myopathy may prolong N-M blockade, so reduce the dose of NMB

• Isoflurane is preferred . • Drugs that stimulate the Sympathetic

nervous system should be avoided (i.e., ketamine, pancuronium, atropine, ephedrine, epinephrine)

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Reversal and Extubation:

• With Inj. Neostigmine 0.05 mg/kg + Inj. Glycopyrrolate 0.01 mg/kg

• A laryngoscopy can be performed to view the vocal cord to exclude any recurrent laryngeal nerve palsy.

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POSTOPERATIVELY

• Removal of the thyrotoxic gland does not mean immediate resolution of thyrotoxicosis.

• The T1/2 of T4 is 7 to 8 days; therefore, β-blocker therapy may need to be continued in the postoperative period.

• Antithyroid drug therapy can be discontinued

Complications of Thyroid Surgery

1. Intraoperative:

• Carotid sinus stimulation - bradycardia + hypotension

• Tachycardia

• Thyroid crisis

• Haemorrhage38

• Tracheal injuries,

• Pneumothorax,

• Pneumomediastinum

• Damage to nerves.

• Atrial fibrillation39

2. Post operativeImmediate Late

Thyroid crisis Hypoparathyroidism

Haematoma Hypothyroidism

hypocalcemia

Tracheomalacia

Damage to nerves

Laryngeal oedema

Hypoparathyroidism 40

Thyroid storm • Is a life threatening emergency

• Characterized by sudden appearance of clinical signs of hyperthyroidism due to the abrupt release of T4 and T3 into circulation.

• Mortality is as high as 25% to 30%.

• Commonly associated with Grave's disease. 41

Predisposing conditions:

• Medical factors :• Infection• Fever• Uncontrolled toxicity• Irregular drug intake• Pregnancy, toxemia of pregnancy• Radio iodine therapy• DKA.

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Surgical factors:

• Anxious and nervous patient before surgery,

• Too much handling of gland just before surgery.

This can occur both intraoperative or in the immediate post operative period, but the latter is more common between 6-18 hours post operatively.

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Clinical features :

• Hyperthermia: rise of 2°C/hr over normal temperature

• Tachycardia: arrhythmias commonly atrial fibrillation

• Initially flushing and sweating later leading to dehydration

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• CCF - initially high output failure, Later may go for Low output failure.

• Shock - cardiogenic/hypovolemic

• Electrolyte imbalance

• Hypo/hyperglycemia may also be present.

• Marked anxiety, agitation, psychosis.45

Differential Diagnosis

• Malignant hyperthermia

• Profound hypercarbia.• Muscle rigidity• Increased ser.ceatinine kinase levels• Lactic /respiratory acidosis

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TREATMENT• Correct the precipitating cause• Ensure adequate oxygenation(100%)• Apply cooling blankets,cold lavage of body cavities,ice packs• glucose-containing intravenous fluids• β-adrenergic blockers-(propanolol/esmolol)• sodium iodide,potassium iodide• propylthiouracil or methimazole• Glucocorticoids• Digoxin in case of atrial fibrillation• Correct electrolyte imbalances• Correct acid-base imbalances• Administer acetaminophen-aspirin is avoided as it displaces

thyroid hormones from binding site &increases free hormone levels

Nerve palsyUnilateral Recurrent laryngeal nerve

palsy

Pt may present with• In INCOMPLETE palsy

– only abductors are paralysed, – Vocal cord assumes median position. – Voice is unaffected & – Pt remains asymptomatic.

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• UNILATERAL COMPLETE palsy

– both abductors & adductors are paralysed, – vocal cord assumes paramedian position, – hoarseness of voice present,

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Bilateral Recurrent Laryngeal Palsy

• Both vocal cords assume median/paramedian position.

• Severe inspiratory dyspnea with stridor may result if paralysis is sudden in onset

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Hypoparathyroidism

• Mainly due to vascular spasm of parathyroid glands & rarely due to accidental removal of parathyroids.

• Occurs in 2nd -5th postop day.

• Presentation – Weakness.– Chvostek`s sign +ve.– Carpopedal spasm– Convulsions

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REGIONAL ANESTHESIA • successfully as the sole anaesthetic technique particularly in areas

with limited resources.

• A commonly used technique is bilateral C2-C4 superficial cervical plexus block performed under full monitoring with or without sedation.

• Adrenaline should be avoided in local anaesthetic mixture.

• The nerves supplying the anterolateral part of the neck emerge from the posterior border of sternocleidomastoid (SCM) as the anterior rami of C2-C4, which divide into greater auricular, transverse cervical, lesser occipital and supraclaviclar nerves

• Regional anaesthesia -avoids the risks of a GA

• allows intraoperative voice monitoring and provides excellent postoperative analgesia.

• The technique may be suited to medically compromised patients ( thyrotoxicosis), or those with obstructive symptoms secondary to large goitres to avoid the risks of a general anaesthesia.

TAKE HOME MESSAGE• Patients should be clinically and chemically euthyroid prior to

thyroid surgery• Perioperative airway complications are common and the

expected or unexpected difficult airway should be anticipated.• Postoperative complications of haematoma formation,

recurrent laryngeal nerve palsy, hypocalcaemia and tracheomalacia can all cause airway compromise and must be acted upon quickly.

• Communication between the surgeon and anesthetist is vital for comprehensive and safe intraoperative management. A postoperative assessment is important to ensure that the patient’s airway remains patent and hemodynamic stability is maintained.