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1. Massive Goitre posted for Thyroidectomy Case Presentation Presenter : Dr. NADIA SHAKIL AHMED Moderator : Dr. P ALLAVI AHLUWALIA ( Prof essor ) Total no of slides : 39 1

2. Chief complaints • 40 yr old female • Housewife • Resident of Moradabad • Painless swelling in front of neck X 5yrs • Dyspnoea on lying down X 2wks 2

3. History of present illness • Swelling in front of neck for past 5yrs. • Insidious in onset, initially noted on right side of neck and gradually increased and extended to left side of neck. • Moves with deglutition. • Dyspnoea on lying down since 2wks which is relieved on left lateral position. Also prefers lying propped up with pillows. 3 No hoarseness of voice. • No h/o dysphagia, drooping of eyelids, absence of sweating, recurrent fever/URTI. • No other swellings elsewhere.

4. • No h/o palpitation, tremors, anxiety, restlessness, weight loss, weakness, heat intolerance, menstrual abnormalities, protrusion of eyeball/double vision, skin lesions. • No h/o weight gain, cold intolerance, hair loss, weakness, depression, increased sleep, swelling of limbs/ drying of skin. • No hemoptysis/ jaundice/bone ache. • Presently good effort tolerance -climb >2 flight of stairs. 4

5. Past history • No DM/HTN/COPD/BA/CAD/CVA/PTB/Malignancy. • No h/o previous hospitalization/operative intervention/radiation • No h/o drug allergy. Treatment history: Not on any regular medications. 5

6. Family history: No history of thyroid illness running in the family Menstrual history • Menarche: 13yrs • Regular 30day cycle- 4days duration • No h/o amenorrhea/ dysmenorrhea/menorrhagia Marital history • Nonconsanguinous marriage • 2kids • P2L2 6

7. Personal history: A p petite: mixed diet Bowel & bladder normal No substance abuse No h/o any addiction Sound sleep, prefers to lie in left lateral position/ propped up with pillows Socioeconomi c status Modified kuppuswamy score: middle class. 7

8. General examination • Conscious oriented • Comfortable at rest • Fairly built and nourished. • Height =160cm, weight= 60kg, • Skin normal. BMI 23.4kg/m2 8

9. No H/o Pallor Icterus Cyanosis Clubbing Lymphadenopathy Edema Eye signs : Exophthalmos Stellwag sign VonGraefes sign Joffroys sign Mobius sign Dalrymple sign 9

10. Vitals Pulse: 78/min, regular rhythm No radioradial / radiofemoral delay. Normal character, and pulse volume. Sleeping pulse rate: 76/min Carotid pulsation felt, undisplaced BP: 120/80mmHg left arm sitting position. RR: 18/min, regular, abdominothoracic, no accessory muscles in use. 10

11. Airway examination • No gross facial dysmorphisms • B/L nasal passages patent- no DNS • Mouth opening >2F • Interincisor distance= 3.5cm • MMP class 2 • MD not measured. • SMD =13.5cm • Neck movements normal • Tongue -no macroglossia • Dentition: no loose tooth/dentures • Palate normal 11

12. • TMJ - no ankylosis, 1 finger insinuated • Upperlip bite test gr 2. • No retrognathia • Submandibular space soft • Neck circumference= 30 cm • Neck movement- normal • Spine normal 12 • Temperature 36°C(axilla) • SPO2: 97% (RA) • No tremors over hands/ tongue • JVP not raised

13. Examination of swelling Inspection Large swelling ,uneven surface over anterior aspect of neck between the 2 SCMs, Lower border reaching just above the sternal notch. Lower border visible Moves with deglutition Doesn't move with protrusion of tongue Right lobe appears bulkier Skin over mass normal, no sinus/ ulcer/scar/dilated veins present/pulsations 13

14. Palpation Neck slightly flexed, standing in front of patient. Large firm mass of 10cmX4cm extending between the 2 SCMs palpated. Upper border 3cm from mentum. Lower border palpable on deglutition, 2.5cm above sternal notch. Bosselated surface with no local rise in temperature Moves with deglutition Not fixed to skin. Trachea palpable , displaced to left Carotid artery palpable, not displaced.No bruit. Kocher's test -ve, Pemberton's test -ve. 14

15. Percussion : Resonant note over manubrium sternum Auscultation: No carotid bruit. Cardiovascular system • JVP not raised, no dilated veins/ scars • Palpation: apex beat at 5th LICS 1cm medial to MCL • No parasternal heave/ palpable heart sounds/thrill/pulsation • S1S2 heard. No murmur/OS/EC 15

16. Respiratory system • No use of accessory muscles. • Chest normal on inspection • Trails sign +ve • Bilateral normal vesicular breath sounds . No adventitious sounds. • Forced expiratory time= 3secs. 16

17. Central nervous system • Conscious oriented • Cranial nerves intact • Motor system- DTR gr2, power 5/5 UL and LL bilaterally tone normal. • Sensory system: normal • No signs of cerebella dysfunction. Gastrointestinal system • Per abdomen- soft and nontender • Bowel sounds normal. 17

18. Provisional diagnosis • 40year old female presented with large thyroid swelling • With tracheal compression, • With no other pressure symptoms and • No retrosternal extension • No features suggestive of hyperthyroidism/hypothyroidism and • No comorbidities, • Scheduled for thyroidectomy. 18

19. SPECFIC INVESTIGATION Thyroid Profile: T3-0.9 ng/ml(0.8-2.0) T4-9.4 ug/dl(5.1-14.1) TSH-1.3 uIU/ml(0.27-5.2) FNAC - not significant of any malignancy X-Ray neck ( lateral view)- not significant ( AP view) – not significant Radioactive iodine uptake - I123, I131 & Tc99. Varies directly with functional state of thyroid. Indirect laryngoscope – Preoperatively done for vocal cord movement.

20. PROVISIONAL DIAGNOSIS 40 year old female presented with large thyroid swelling. With Tracheal compression. With no other pressure symptoms. No retrosternal extension. No features of Hypo/Hyperthyroidism. No comorbidities. Posted For Thyroidectomy.

21. INVESTIGATIONS 21 Routine Investigation: Hb: 12gm/dl TLC: 8000 cells/mm3 Platelets: 1.50,000/mm3 RFT: Urea/ Creat : 40mg/dl/1.0mg/ dI Uric acid - 6.5 Sodium - 137 mEq /I Potassium - 4.2 mEq /I Chloride - 101 mEq /I LFT: SGOT/SGPT: 35/43 Total billirubin:1.1 Direct/indirect bilirubin: 0.6/0.4 INR:1.2 PT:12 secs Viral marker: negative Blood group : o+ve RBS – 104 mg/dl ECG: Normal CXR – Chest x-ray demonstrating marked tracheal deviation to the left due to the mass extending down into the mediastinum from the right neck.

22. Technique of Anaesthesia : General anaesthesia with awake fibere optic intubation using flexometallic Endotracheal tube . 22

23. MANAGEMENT OF ANAESTHESIA INDICATIONS FOR AWAKE INTUBATION Anticipated difficult airway (assessed on physical examination) . The natural airway is preserved in awake intubation. Spontaneous breathing is maintained. A patient who is awake and well topicalized is easier to intubate. The patient can still protect her airway from aspiration.

24. ELEMENTS OF AWAKE INTUBATION (AI) ELEMENTS UNDERLYING CONCEPT EXPLANATION PATIENTS UNDERSTAND SAFETY DESICCATION DRY THE AIRWAY DILATATION PREPARE THE NOSE TROPICALIZATION OBTUND REFLEXES SEDATION MAINTAIN THE PATIENTS AIRWAY CONTROL PROCRASTINATION AI CANNOT AND SHOULD NOT BE RUSHED

25. B. PREPARATION OF THE PATIENT A detailed explanation of the technique is provided, and questions are answered. Reason should be explained to the patient, emphasizing that this is done for the patient's safety. The patient is informed of what he or she can do to assist in a smooth intubation.

26. PRE-OPERATIVE: NPO for 8hrs Written and informed consent were taken for anaesthesia . Two large IV(18G) bore cannula were secured.

27. PREMEDICATION Alleviate anxiety Provide a clear and dry airway Protect against the risk of aspiration Enable adequate topicalization of the airway

28. B . ASPIRATION PROPHYLAXIS H2- RECEPTOR ANTAGONISTS Cimetidine and Ranitidine Selective and competitive antagonists that block secretion ofH+ Ranitidine : 0.25-1.0 mg/kg i.v Cimetidine : 5- 10 mg /k PO METOCLOPRAMIDE Dopamine antagonist Doses are 0.15 to 0.3 mg/kg IV. For complete aspiration prophylaxis, a combination of nonparticulate antacid, H2- receptor blocking agent, and metoclopramide may be used.

29. C. ANTISIALOGOGUES . , » Glycopyrrolate » Dos e - 0.2 mg I.V . Onset in 1 to 2 minutes . 20 min. before intubation

30. D. Nasal mucosal vasoconstrictors Patient adequate requires anesthesia awake of this nasal intubation, area, along with vasoconstriction, is essential . Agent commonly used are 4% cocaine and 2% lidocaine with 1% phenylephrine . Adequate anesthesia and vasoconstriction can be achieved in 10 to 15 minutes . Nasal decongestants 0.025% to 0.05% o xymetazoline hydrochloride nasal solution sprayed twice in each nostril .

31. INTRAOPERATIVE The patient was shifted to the operating theater. Standard ASA monitors (electrocardiogram, non-invasive blood pressure, and pulse oximeter). Temperature probe, neuromuscular monitors were attached. Her baseline vitals were noted which was within normal limits. BP- 118/70mmgh PR- 86/min SPO2-98% 0n RA RR-16/min

32. PREMEDICATION : Inj. Fentanyl 75 mcg iv Inj. Midazolam 1 mg iv Inj. Glyco 0.2mg iv Inj. Dexamethasone 8 mg iv Patient was preoxygenated with high flow nasal cannula . Induced with Inj. Thiopentone 240 mg iv Relaxed with inj. vecuronium 4 mg iv Patient was intubated with 7mm flexomettalic tube and put on mechanical ventilator after fixing and securing b/l air entry.

33. SPRAY GO TECHNIQUE Noninvasive and involves injecting local anesthetics through the suction port of the FOB. It requires attaching a triple stopcock to the proximal portion of the suction port in order to connect oxygen tubing to flow at 2 to 4 L/min. Under direct vision through the bronchoscope, targeted areas are sprayed with aliquots of 0.2 to 1.0 mL of 2% to 4% lidocaine. The physician then wait 30 to 60 seconds before advancing to deeper st ructure and repeating the maneuver .

34. Induced with Inj. Thiopentone 240 mg iv Relaxed with inj. vecuronium 4 mg iv Patient was intubated with 7mm flexomettalic tube and put on mechanical ventilator after fixing and securing b/l air entry. Patient is positioned with neck extended with sand bag between the shoulder blades and the head resting on a head ring. Arms should be secured by the side, padded and protected. Eye was covered with soft pad.

35. Maintenance: Inhalational agent: isoflurane With O2 and N2O Inj. Vecuronium 1mg iv intermittent. IV fluid RL was started Foley's catheter inserted. PCM: Inj. 900 mg iv. Inj. Fentanyl 25mcg iv given. Inj . Trenexa 1gm iv At the end of surgery- After gentle suctioning patient was reversed with Neostigmine (0.04 mg/kg) and Glycopyrrolate (0.01 mg/kg)

36. EXTUBATION An awake gradual extubation was done after leak test and patient was reversed with neostigmine and glycopyrrolate. Postextubation , bilateral vocal cord movement was checked with glidescope that was normal. Patient was kept in surgical Intensive Care Unit for observation in the postoperative period. Pain management was given via multimodal analgesia.

37. POST-OPERATIVE: Patient was conscious, cooperative. Her vitals were stable. S he was supplemented with face mask. Postoperative pain managed by multimodal analgesia. P ostoperative course was uneventful .

38. Thank you 39