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Sabaretnam Mayilvaganan, Amit Agarwal 10.5005/jp-journals-10002-1145

How i do it

Management of post-thyroidectomy tracheomalacia

1
Sabaretnam Mayilvaganan, 2Amit Agarwal

ABSTRACT segment. In diffuse tracheal disease, the trachea usually

Tracheomalacia is a heterogeneous and complex entity with no distends and collapses unevenly during inspiration and expi-
universally accepted definition and stratification. Historically, it ration, thus interfering with the tracheal function (Fig. 1).1-3
is considered that patients with very large goiters are at risk of Multiple preoperative risk factors in a patient with large
developing post-thyroidectomy tracheomalacia (PTTM). PTTM
is a rare phenomenon and can be managed by either Non- goiter like goiter for more than 5 years (Fig. 2), preoperative
invasive or invasive options. recurrent laryngeal nerve palsy, significant tracheal narro-
Keywords: Tracheomalacia, Tracheostomy, Thyroid surgery. wing and/or deviation, retrosternal extension, retro tracheal
How to cite this article: Mayilvaganan S, Agarwal A. Manage- extension (Fig. 3), difficult tracheal intubation and thyroid
ment of post-thyroidectomy tracheomalacia. World J Endoc Surg cancer may be useful in predicting the need for planned
2014;6(2):96-98.
tracheostomy following thyroidectomy. Although definitive
Source of support: Nil
criteria are lacking, a cut off of a 50% reduction in tracheal
Conflict of interest: None
lumen is usually considered a prerequisite for diagnosis.
Introduction This relies largely on dynamic imaging, either CT or MRI.
However, in patients with extrinsic compression such as those
Tracheomalacia was first described by Czyhlarz in 1897, due to goiter, tracheomalacia may theoretically only become
and remains a heterogeneous and complex entity with no apparent following removal of their compressive agent.
universally accepted definition and stratification. Adult Consequently, tracheomalacia may present unheralded as
acquired tracheomalacia is most commonly post-traumatic an emergency after thyroidectomy; hence historically, it has
due to prolonged or recurrent intubation. Historically, it is been feared as a complication of thyroidectomy. Though a
considered that patients with very large goiters were at risk number of investigations have been mentioned in the lite­
of developing post-thyroidectomy tracheomalacia (PTTM). rature, in a postoperative patient a high clinical suspicion and
This condition is usually secondary to long-standing extrin- bronchoscopy can be used for effective diagnosis and treat-
sic tracheal compression with subsequent loss of tracheal ment. The airway is directly visualized during spontaneous
cartilage rigidity, culminating in dynamic airway collapse respiration using a flexible bronchoscopy. The findings consist
in excess of 50% of diameter. It is commonly suggested of the triad of loss of normal semicircular shape of tra­cheal
that removal of the compressive source (i.e. thyroidectomy) lumen, forward ballooning of the posterior membra­nous wall
may precipitate life-threatening airway collapse (particu- and anteroposterior narrowing of the tracheal lumen.1-4,6,7
larly during expiration) and potentially mandate emergency
tracheostomy. However, anecdotal evidence from surgeons
with extensive experience suggests that this is almost never
encountered and a rare phenomenon.1-5

Management
Tracheomalacia commonly affects the distal third of the
trachea. Functional impairment is proportional to the length
of the involved segment and degree of stenosis. Furthermore,
kinking may occur at the transition between healthy tracheal
wall and the indurated segment, as well as in the malacic

1
Assistant Professor, 2Professor
1,2
Department of Endocrine Surgery, Sanjay Gandhi Postgra-
duate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Corresponding Author: Sabaretnam Mayilvaganan, Assistant
Professor, Department of Endocrine Surgery, Sanjay Gandhi Post­
graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
India, Phone: 919655851510, e-mail: drretnam@gmail.com Fig. 1: Cross-section of normal trachea and tracheomalacia
during inspiration and expiration

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Management of post-thyroidectomy tracheomalacia

– volume pressure loop on ventilator or

– development of respiratory stridor along with falling
hemoglobin oxygen saturation (SpO2) on pulse oxi­
metry despite the administration of increasing FiO2.5
The typical manifestation of postoperative tracheoma-
lacia is acute respiratory distress following extubation not
explained by any other cause. This invariably necessitates
prompt re-intubation or a tracheostomy, following which
the distress is promptly relieved. Anticipation of possible
tracheomalacia helps in instituting preventive or prompt
remedial measures.5
We recommend treating postoperative tracheomalacia
following thyroidectomy expectantly. Mild variants, which
Fig. 2: Longstanding multinodular goiter may not be recognized postoperatively, may be managed
with respiratory exercises. Mask ventilation using a CPAP
mode may also be a useful adjunct. The majority will respond
to conservative management, consisting of humidified air,
chest physical therapy, slow and careful feedings to prevent
aspiration, and control of infection and secretions with anti-
biotics.

Prolonged Intubation
Patients who are unable to maintain oxygen saturation with
these measures may be managed with intubation for longer
periods. When extubation after about 2 weeks becomes
a problem, we perform tracheostomy. The inflammatory
response that sets in due to the indwelling tracheostomy or
endotracheal tube leads to a stiffening of the tracheal wall
Fig. 3: X-ray showing tracheal narrowing and also thereby preventing the expiratory collapse. This is paradoxi-
retrotracheal extension
cal since a long-standing tracheostomy tube can result in
The important point is recognition of tracheomalacia on tracheomalacia because of pressure-related degeneration of
the operating table before extubation. There is no single fool- the tracheal cartilages.
proof criterion for confirming a diagnosis of tracheomalacia.
Tracheostomy
However, for the intraoperative diagnosis of tracheomalacia,
we have taken one or more of the following criteria: We prefer to go for an intraoperative tracheostomy if there
• Soft and floppy trachea on palpation by the surgeon is definite softening of the trachea6,7 we think that it is better
at the end of thyroidectomy. However, because of to do a tracheostomy at the time of surgery, as it is easier
splinting effect of the endotracheal tube (ETT) in situ, to visualize the part of trachea most suitable for tracheos-
it is difficult to appreciate a soft trachea. We therefore tomy. Further, the tracheal toilet as well as ventilator care,
ask the anesthesiologist to gradually withdraw the tube if needed, is easier in patients with tracheostomy than in
for a short distance and then feel the tracheal without the those with the ETT kept in place. Unlike prolonged intuba-
tube in site. This maneuver may also help the surgeon tion, tracheostomy results in fibrosis around a soft trachea
recognize an obvious collapse of the tracheal wall. resulting in early recovery from tracheomalacia. We also
• Obstruction to spontaneous respiration during gradual did not encounter any cases of tracheal stenosis following
withdrawal of the ETT after thyroidectomy. tracheostomy for tracheomalacia. Most of the tracheos-
• Difficulty in negotiating the suction catheter beyond the tomized patients had their tracheostomy tube removed after
ETT after gradual withdrawal. an week (Fig. 4A).
• After closure of the wound, tracheomalacia can be
Tracheopexy
suspected:
– if there is absence of peritubal leak on deflation of We prefer this technique in short segment lateral tracheoma-
ETT cuff lacia. We use fixation sutures to anchor the tracheal rings to
World Journal of Endocrine Surgery, May-August 2014;6(2):96-98 97
Sabaretnam Mayilvaganan, Amit Agarwal

both clavicles to maintain an anterolateral counter traction an internal stent and prevent tracheal collapse after with-
on the anterior wall of the trachea, so that it prevented its drawal of the endotracheal tube in patients with tracheo-
backward collapse and kept the airway patent8 (Fig. 4b). malacia, thereby providing a potential therapeutic benefit.
Noninvasive positive pressure ventilation with bi-level posi­-
Noninvasive positive tive airway pressure mode delivers positive airway pressure
pressure ventilation both during inspiratory and expiratory phases. We use BIPAP
ventilation for 48 hours.9
We prefer this technique in short segment tracheomalacia.
These are the techniques we usually use and we have little
The positive airway pressure delivered by NPPV can act as
experience of using intraluminal tracheal splints and auto-
logous costal cartilage ring grafts to support the trachea ante-
riorly.

References
1. Lee C, Cooper RM, Goldstein D. Management of a patient with
tracheomalacia and supraglottic obstruction after thyroid surgery.
Can J Anaesth 2011 Nov;58(11):1029-1033.
2. Krishnan H, May RE. An unusual cause for respiratory difficulty
after thyroidectomy. Br J Clin Pract 1993 Jan-Feb;47(1):47-48.
3. ElBashier EM, Hassan Widtalla AB, ElMakki Ahmed M.
Tracheostomy with thyroidectomy: indications, management and
outcome: a prospective study. Int J Surg 2008 Apr;6(2):147-150.
4. Randolph GW, Shin JJ, Grillo HC, Mathisen D, Katlic MR,
Kamani D, Zurakowski D. The surgical management of goiter:
part II. Surgical treatment and results. Laryngoscope 2011 Jan;
A
121(1):68-76.
5. Agarwal A, Mishra AK, Gupta SK, Arshad F, Agarwal A,
Tripathi M, Singh PK. High incidence of tracheomalacia in
longstanding goiters: experience from an endemic goiter region.
World J Surg 2007 Apr;31(4):832-837.
6. Abdel Rahim AA, Ahmed ME, Hassan MA. Respiratory
complications after thyroidectomy and the need for tracheostomy
in patients with a large goiter. Br J Surg 1999 Jan;86(1):88-90.
7. McHenry CR, Piotrowski JJ. Thyroidectomy in patients with
marked thyroid enlargement: airway management, morbidity,
and outcome. Am Surg 1994 Aug;60(8):586-591.
8. Ağaoğlu N. Tracheopexy for tracheomalacia complicating a
giant multinodular goiter: a case report. Acta Chir Belg 2007
Jul-Aug;107(4):460-461.
9. Chi SY, Wu SC, Hsieh KC, Sheen-Chen SM, Chou FF. Non­
invasive positive pressure ventilation in the management of
B
post-thyroidectomy tracheomalacia. World J Surg 2011 Sep;
Figs 4A and B: (A) tracheostomy and (B) tracheopexy 35(9):1977-1983.

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