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Thyroidectomy in Pregnancy: Complex Airway Management for Patient Presenting with Biphasic Stridor
Abstract Number: T4C-2
Abstract Type: Case Report/Case Series
29 y/o G2P1001 at 29 1/7 weeks EGA with medical history significant for GERD and Graves disease treated with methimazole and atenolol presented for total thyroidectomy secondary to worsening severe obstructive symptoms. Symptoms included dyspnea at rest in upright position and stridor in addition to exophthalmos, tremors, diarrhea, palpitations, and heat intolerance. An ENT consultant performed nasopharyngoscopy which demonstrated a widely patent airway at 60 degree elevation, and fully abducting and adducting vocal cords without obvious tracheal compression. In the supine position, patient experienced biphasic stridor but was able to maintain normal oxygen saturation. Airway exam revealed Mallampati class 2 airway. CT demonstrated diffuse enlargement of the thyroid (lobes 9x5x5.4cm bilaterally) with tracheal narrowing to 5 mm in transverse dimension (Figure 1). After decision was made to perform thyroidectomy, betamethasone was administered for fetal lung maturation.
Extensive multidisciplinary preoperative airway planning between ENT and OB anesthesia was conducted in anticipation of a difficult airway secondary to tracheal narrowing from thyroid hypertrophy and oropharyngeal edema due to pregnancy. Plan was for awake oral fiberoptic intubation to avoid rapid desaturation and potential for complete airway obstruction with apnea. This was facilitated by extensive local anesthetic topicalization, adminstration of an anti-sialogue, and dexmedetomidine for sedation and anxiolysis. ENT was present during intubation with a rigid bronchoscope available. Uneventful awake intubation occurred with fiberoptic visualization of trachea, bilateral lung auscultation, and confirmation of ETCO2. General anesthesia was then induced with propofol and fentanyl. Continuous FHR monitoring was performed by a L&D nurse without issue. Patient tolerated the procedure well without complications and was discharged on POD 2. She had an uncomplicated delivery at 33 weeks EGA.
This case highlights the importance of multidisciplinary care for high-risk obstetric patients. Dexmedetomidine was used for anxiolysis without signs of fetal bradycardia, and awake fiberoptic intubation with rigid bronchoscope available was used to mitigate the risk for airway collapse.