Invasive tracheal tumor complicated by five tracheal ring resection, tracheal reconstruction, and tracheostomy
Madison Garrity, DDS1, Sierra Bodily, DDS1, Slawomir Oleszak, MD1, Martin Boorin, DMD1, Ralph Epstein, DDS1, Alexander Bjorling, MD2, Lukasz Czerwonka, MD2
1Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University
2Department of Surgery, Division of Otolaryngology–Head and Neck Surgery, Renaissance School of Medicine, Stony Brook University
BACKGROUND
Thyroid cancer
•US incidence: 13.22 cases per 100,000 individuals with 90% being papillary thyroid carcinomas (PTCs)3
•6%-13% of well-differentiated intra-thyroidal tumors (~91% survival) progress to invasive extra-thyroidal tumors (~45% survival)4
•Most commonly invaded structures:
•Strap muscles (53%), recurrent laryngeal nerve (RLN) (47%), trachea (37%), esophagus (21%), lateral neck vessels and vagus nerve (30%), and larynx (12%)5
•Shin Stage I and IV (Figure 1a/1b)
•I: Abuts external tracheal perichondrium
•IV: full thickness invasion of the tracheal mucosa
•Past Medical History: 68-year-old male with PMH of HLD and pre-diabetes (HbA1c: 5.7); 5-week history of hoarseness and dyspnea
•Flexible laryngoscopy: Left true vocal cord paramedian paralysis, and partial right glottic closure
•CT neck: 2.4 x 2.1 x 2.2 cm left paratracheal mass invading the anterior esophagus and posterior left lower thyroid lobe the level of the thoracic inlet level with lymph node metastasis (level III/IV/Vb), esophageal narrowing, left tracheal effacement, & left RLN paralysis
•Fine needle aspiration biopsy: PTC with hemorrhagic cystic changes
•Surgical plan: Total thyroidectomy, left modified radical neck dissection, central neck dissection, and left RLN neurorrhaphy with possible tracheal resection
INTRAOPERATIVE MANAGEMENT
•IV induction: fentanyl, lidocaine, and propofol
•Intubation: Dual view technique via BF-P190 bronchoscope and GlideScope® video laryngoscope with 7.0 NIM™(neural integrity monitor) EMG (electromyogram) endotracheal tube (ETT)
•Access: right radial arterial line (ABG/BGLs), two peripheral IVs
•Maintenance: propofol/remifentanil
•Analgesia: fentanyl, hydromorphone, ketamine
•PTC (Shin Stage IV) requiring resection of 30% of the trachea
•Resection adjacent to the NIM™EMG ETT cuff and critical neck structures required strategic tube manipulation (Figure 2b)
•FiO2 of 0.3 was used to decrease airway fire risk and during one-lung ventilation, lowest SpO2drop was to 87%
•Tracheostomy was required due to pre-existing left RLN paralysis and intraoperative right RLN paralysis
CONCLUSION
•Successful airway management was executed with no significant reduction in blood oxygen saturation despite the unforeseen challenges of tracheal resection, tracheal reconstruction, and tracheostomy
•Diligent FiO2 and SpO2 monitoring, endotracheal tube manipulation, perioperative tube exchanges, and pain control were critical for successful anesthetic management during this 13-hour procedure
•Following surgical completion, the patient was transferred to the SICU in stable condition, ventilated via the tracheostomy tube, and advised to keep neck in flexion
