Published on 07/02/2015 by admin
Filed under Anesthesiology
Last modified 07/02/2015
This article have been viewed 939 times
Prith Peiris, MD
Although thyroid operations are often viewed as routine procedures, they can present a unique combination of problems for the anesthesia provider. For example, difficulties securing the airway in the presence of a large goiter and surgical trauma to the recurrent laryngeal nerves (RLN) may cause dysphonia and stridor after extubation. The presence of coexisting thyroid hyperfunction or hypofunction, particularly when poorly controlled, can impact morbidity and mortality. Anesthesia can precipitate thyroid storm in patients with hyperfunction of the thyroid; hypofunction, especially of unknown severity, can present as multisystem clinical challenges during both the intraoperative and postoperative periods. Close cooperation between the anesthesia provider and the surgeon is imperative in achieving optimal outcomes in patients undergoing thyroid operations.
Thyroid operations have been successfully completed under local, regional, and intravenous anesthesia; however, most thyroid operations require general inhalation anesthesia. For these patients, a reinforced wire spiral tracheal tube may be necessary to maintain airway patency. (Nerve integrity monitor [NIM] tracheal tubes, which will be discussed in the section Preserving and Assessing the Function of the RLN, are reinforced.)
Intubation issues and potential difficulty in securing the airway in patients with goiters should be anticipated. Positional dyspnea and hypotension may suggest that the patient’s airway or great vein is compressed by a goiter. If the results of the preoperative examination and a review of the patient’s medical records, including the surgeon’s outpatient examination records, suggest that intubation may be difficult in any patient undergoing a thyroid operation, the results of ultrasonography or computerized tomography may assist the anesthesia provider in deciding whether a surgical airway or an awake intubation would be the safer option. In patients with goiters, a radiograph of the chest may reveal any tracheal deviation and airway collapse, but a computerized tomographic scan is better for assessing retrosternal extension, tracheal ring compression, and airway tortuosity.
The overall incidence of RLN damage during thyroid operations is 2% to 5%. Surgical identification and preservation of the RLNs remains the gold standard for protecting the RLN, but real-time intraoperative monitoring of RLN function may also help to reduce the incidence of damage.
Fausts Anesthesiology Review Expert Consult 4e
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