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Journal of Postgraduate Medicine, Vol. 55, No. 3, July-September, 2009, pp. 193-195 Case Report Tracheal necrosis with surgical emphysema following thyroidectomy Chauhan A, Ganguly M, Saidha N, Gulia P Department of Surgical Oncology, Army Hospital (R and R), Delhi Cantt, Delhi - 110 010, India Date of Submission: 23-Mar-2009 Code Number: jp09058 PMID: 19884745 DOI: 10.4103/0022-3859.57401 Abstract Tracheal necrosis after thyroidectomy is an extremely rare event with only a few published reports. We present a case of a 65-year-old male who developed rapidly progressive surgical emphysema of face and upper thorax on the seventh day following total thyroidectomy. Prompt surgical exploration of neck revealed a tracheal rent at the level of the second tracheal ring. This hole was then refashioned into a formal tracheostomy. Patient had an eventful recovery. Tracheostomy was closed by the 14 th day. The complication was probably related to tracheal injury sustained due to electro-coagulation and subsequent secondary infection.Keywords: Surgical emphysema, thyroidectomy, tracheal necrosis Tracheal necrosis after thyroidectomy is extremely rare. [1] We present a patient of longstanding medullary carcinoma thyroid who underwent total thyroidectomy and bilateral neck dissection, and thereafter suddenly developed rapidly increasing surgical emphysema of the upper torso in the late postoperative period. Subsequent exploration of neck revealed a leak from the trachea secondary to localized tracheal necrosis. The possible etiologies are discussed. Case Report A 65-year-old male presented with a progressively increasing thyroid swelling for the past two years. Clinically, he had a diffuse enlargement of the thyroid measuring 20 x 20 cm with bilateral cervical lymphadenopathy. Medullary carcinoma of the thyroid gland was diagnosed on the basis of Fine Needle Aspiration Cytology (FNAC). Contrast-enhanced computed tomography scan of the neck, chest and abdomen revealed diffuse enlargement of both lobes and isthmus of thyroid with the right and left lobes measuring 8 Χ 6.5 Χ 6 cm and 7 Χ 3 Χ 5 cm, respectively. There was retrosternal extension of 2 cm, as well. A soft tissue mass suggestive of confluent lymph nodes measuring 7 Χ 6 Χ 6 cm was seen in the anterosuperior mediastinum. It extended up to the carina. Level I, II,III, IV, V and VI cervical lymph nodes [Figure - 1] were present bilaterally. Ultrasound examination of the abdomen revealed multiple liver metastases. The patient was diagnosed to have medullary carcinoma thyroid T4aN1bM1 (Stage IVc). The patient underwent total thyroidectomy with bilateral modified neck dissection. Per-operatively, the patient was found to have enlarged multilobulated thyroid gland densely adherent to the overlying strap muscles and the underlying trachea. The confluent lymph node mass on the right side infiltrated the prevertebral fascia. Total thyroidectomy with as maximal an excision of the lymph node mass as was safely possible, was done. The patient was extubated uneventfully and was noted to have bilateral vocal cord movements. After a relatively uneventful postoperative recovery, the patient developed rapidly progressive, surgical emphysema on the seventh postoperative day. It initially involved the face, and rapidly spread to involve the whole of the upper torso [Figure - 2]. The patient developed acute respiratory distress and had to be intubated under fibreoptic guidance. Surgical exploration of the neck was carried out. An irregular 5-mm hole with necrotic edges was found in the trachea at the level of the second tracheal ring. The necrotic edges were debrided and the hole in the trachea was fashioned into a formal tracheostoma. A 7.5 Fr tracheostomy tube was inserted through the stoma and the neck wound closed over a suction drain in situ. Patient was extubated successfully. His surgical emphysema subsided over the next 72 h. He was decannulated after five days and tracheostomy could be closed successfully by the 14th day. Discussion Airway disruption, as a result of tracheal necrosis and spontaneous perforation, has been previously reported as a secondary effect of radiotherapy and chemotherapy. [2],[3] Iatrogenic tracheal disruption has also been reported after prolonged intubation, and this has been attributed either to direct traumatic injury or as a complication of pressure-induced ischemia resulting in tissue necrosis. [4] However, tracheal necrosis after thyroidectomy has been reported only a few times earlier. [1],[5] These authors have suggested use of excessive cautery on and around the trachea, as the possible reason for such an injury. It is known that electro-coagulation done to control bleeding has the potential risk of injuring the surrounding structures from lateral dispersion of heat [6] and an inadvertent tracheal injury which may not be noticed immediately. Consequent to this, there would be presence of necrotic debris and localized hematoma. This would then form a nidus for superadded bacterial infection which, subsequently could lead to necrosis. It is our standard practice to use bipolar cautery with low power setting while doing a thyroidectomy to prevent inadvertent injury to recurrent laryngeal nerve. Tracheomalacia is the other possible etiological factor for such an injury. It is a dynamic airway compression of the airway due to tracheal collapse secondary to loss of the supporting elastic and/or cartilaginous elements. This can be acquired due to the degeneration of the normal tracheal wall support elements secondary to compression. [7] However, we think that tracheomalacia is unlikely to be responsible for the tracheal rent in our case, because the thyroid enlargement was of relatively short duration and also that the patient manifested later in the postoperative period. It is well known that tracheomalacia tends to manifest immediately on extubation or in the early postoperative period. Our patient was subjected to total thyroidectomy, bilateral neck dissection and upper mediastinal dissection, with consideration of the fact that in metastatic medullary thyroid cancer, surgical resection may still offer the best chance of survival as well as long-term palliation. [8] In view of the extensive bilateral neck and mediastinal dissection undertaken, the possibility of ischemic necrosis of the tracheal wall exists. It has been demonstrated in autopsy studies that the blood supply to the upper segment of the trachea comes mainly from small branches of the inferior thyroid artery that have lateral points of entry. [9] These fragile vessels are easily disturbed, causing ischemia and subsequent necrosis. Indeed, it has been seen that cervical and upper mediastinal lymph node dissections made during an esophagectomy lead to ischemic changes that cause ulceration and necrosis in the tracheobronchial mucosa. [10] Once the patient developed the air leak, his situation might have been aggravated by the vigorous coughing which was being encouraged as part of chest physiotherapy. Tracheal disruption produces rapidly progressive surgical emphysema which is potentially life-threatening. Though it may be diagnosed on fibreoptic bronchoscopy, [1] it is prudent to explore the neck at the earliest so that a lifesaving tracheostomy can be done in the same sitting. In our case, inadvertent minor injury to trachea may have ensued during dissection of the thyroid off the trachea which may have gone unnoticed per-operatively. But, in the postoperative period, this injury coupled with possible ischemia as outlined before, may have led to the tracheal necrosis. Prompt re-exploration of the neck and tracheostomy prevented any untoward outcome. References
Copyright 2009 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp09058f2.jpg] [jp09058f1.jpg] |
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