Anesthetic management of retrosternal goitre complicated by
A 71-year-old obese female with American Society of Anesthesiologists physical status III, body mass index of 35.6 kg/m2, height of 165 cm, and weight of 97 kg presented for total thyroidectomy with partial sternotomy. She initially visited the Otolaryngology Clinic for evaluation of bilateral upper extremities edema for the past 8 months. The patient had complaints of intermittent episodes of dyspnea, dysphagia of dry solid food, and malaise. She was recently diagnosed with OSA by nocturnal polysomnography but failed to tolerate continuous positive airway pressure (CPAP) device during sleep.

Her past medical history was significant for pulmonary hypertension, Sjogren's syndrome, chronic atrial fibrillation, portal hypertension in the setting of primary biliary cirrhosis, and hypertension secondary to hyperaldosteronism. Physical exam revealed diffuse non-pitting edema of bilateral upper extremities, palpable enlarged neck mass, and venous engorgement of chest and arm vessels. Airway examination showed Mallampati classification III and thyromental distance was more than three finger breadths with full range motion of the neck. Auscultation of the heart revealed an irregularly irregular rhythm and a grade 2/6 systolic ejection murmur. Transthoracic echocardiography (TTE) revealed pulmonary hypertension with an estimated pulmonary artery systolic pressure of 43 mmHg. Computerized tomography (CT) scan of the thorax revealed a massive nodular goiter measuring 8.36 x 5.37 x 8.08 cm with retrosternal extension into the anterior mediastinum. The mass caused left tracheal deviation with mild narrowing and compression of both brachiocephalic veins at the level of thoracic inlet. The patient was diagnosed with massive nodular goiter complicated by SVC syndrome. Total thyroidectomy with median partial sternotomy was planned

Sedation was initiated with 2.5 mg of midazolam and 75 µg of fentanyl, and 0.2 mg of glycopyrrolate was administered intravenously as an antisialogue. Following placement of a radial arterial catheter and a second large-bore peripheral intravenous catheter, the oral mucosa was anesthetized topically with 3 mL of 4% lidocaine. Intubation was achieved with the patient maintaining spontaneous ventilation and a flexible bronchoscope. A neural integrity monitor electromyogram tracheal tube was placed to allow continuous auditory feedback to the surgeon to guard against injury to the recurrent laryngeal nerves.

The intraoperative course was uneventful. A conventional transcervical resection with partial sternotomy was performed to surgically remove the retrosternal goiter. The patient was extubated once she was fully awaked and had an uncomplicated post-operative course and was discharged home on post-operative day two
Anesthetic management of patients with anterior mediastinal mass and SVC syndrome is complicated. These patients reportedly have increased risks of cardiorespiratory complications due to compression of the airway, great vessels, and heart by local mass effect . Obstruction of the SVC can lead to impaired venous return and result in significantly diminished cardiac output. General anesthesia can magnify these changes through vasodilatation in which can produce severe hemodynamic compromise and tissue ischemia. These cardiorespiratory complications can be difficult to predict solely based on the severity of symptoms caused by anterior mediastinal mass. Careful anesthetic planning must be done properly and thoroughly as the clinical status of these patients can rapidly deteriorate upon induction of anesthesia.

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