Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review

Abstract

BackgroundAcute respiratory failure due to thyroid compression or invasion of the tracheal lumen is a surgical emergency requiring urgent management. The aim of this paper is to describe a series of six patients treated successfully in the emergency setting with total thyroidectomy due to ingravescent dyspnoea and asphyxia, as well as review related data reported in literature.MethodsDuring 2005-2010, of 919 patients treated by total thyroidectomy at our Academic Hospital, 6 (0.7%; 4 females and 2 men, mean age: 68.7 years, range 42-81 years) were treated in emergency. All the emergency operations were performed for life-threatening respiratory distress. The clinical picture at admission, clinical features, type of surgery, outcomes and complications are described. Mean duration of surgery was 146 minutes (range: 53-260).ResultsIn 3/6 (50%) a manubriotomy was necessary due to the extension of the mass into the upper mediastinum. In all cases total thyroidectomy was performed. In one case (16.7%) a parathyroid gland transplantation and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and 4 pleural effusions, treated by medical therapy in 3 and by drains in one. There was no mortality.ConclusionOn the basis of our experience and of literature review, we strongly advocate elective surgery for patients with thyroid disease at the first signs of tracheal compression. When an acute airway distress appears, an emergency life-threatening total thyroidectomy is recommended in a high-volume centre.

Management of airway compromise following thyroid cyst hemorrhage after thrombolytic therapy

“…Spontaneous hemorrhage within goiters is thought to be caused primarily by venous rupture due to deficient adventitia, musculature, and elastic tissue of veins within the goiter, accompanied by robust arteriovenous shunting. 3 Plentiful capsular vessels may anastomose with vessels that penetrate into the core of the mass. Adenomatous goiters lack a strong capsule and experience increased vascular flow, making them particularly vulnerable to traumatic bleeding.…”

“…2 These emergencies were often preceded by progressive dyspnea before the onset of respiratory distress; sudden-onset respiratory distress suggests concomitant vocal cord paresis or massive intrathyroid hemorrhage. 3 Intrathyroid hemorrhage sufficient to compromise the airway is rare and usually follows blunt trauma or iatrogenic insult to the neck as in fine-needle aspiration. [3][4][5] Spontaneous hemorrhage into a thyroid mass has also been described, perhaps resulting from unidentified physical exertion or the use of oral anticoagulants such as aspirin or warfarin.…”

“…3 Intrathyroid hemorrhage sufficient to compromise the airway is rare and usually follows blunt trauma or iatrogenic insult to the neck as in fine-needle aspiration. [3][4][5] Spontaneous hemorrhage into a thyroid mass has also been described, perhaps resulting from unidentified physical exertion or the use of oral anticoagulants such as aspirin or warfarin. [3][4][5][6] Tissue plasminogen activator (tPA) is a thrombolytic agent accepted as therapy for selected cases of acute ischemic cerebrovascular insults, pulmonary embolism, myocardial infarction, deep venous thrombosis, and portal vein thrombosis.…”

“…[3][4][5] Spontaneous hemorrhage into a thyroid mass has also been described, perhaps resulting from unidentified physical exertion or the use of oral anticoagulants such as aspirin or warfarin. [3][4][5][6] Tissue plasminogen activator (tPA) is a thrombolytic agent accepted as therapy for selected cases of acute ischemic cerebrovascular insults, pulmonary embolism, myocardial infarction, deep venous thrombosis, and portal vein thrombosis. A rare side effect of tPA's thrombolytic activity is spontaneous hemorrhagic complications in other organ systems, such as ocular hemorrhage, hemopericardium, hemorrhage into ovarian cystadenocarcinoma, or splenic hemorrhage.…”

Acute respiratory failure in a rapidly enlarging benign cervical goitre

“…Testini et al 11 described six cases of goitres presenting with acute airway obstruction out of a total of 919 patients who underwent thyroidectomy. However, only two of these (0.2%) were confirmed to be benign by histology, one of which was noted to have had massive parenchymal haemorrhage.…”