Table of Contents

2017 Month : June Volume : 3 Issue : 1 Page : 22-24

A CASE OF SURGICAL EMPHYSEMA WITH RESPIRATORY DISTRESS FOLLOWING THYROID SURGERY FOR MULTINODULAR GOITRE DUE TO BILATERAL PNEUMOTHORAX AND PNEUMOMEDIASTINUM.

Sivakumar R. Pillai1, Suresh Babu2, Biju C. Nair3

Corresponding Author:
Dr. Sivakumar R,
Pillai, Vasanth, Ekra 38,
Kariyam, Powdikonam,
Trivandrum-695588, Kerala, India.
E-mail: ssivapillai75@gmail.com

ABSTRACT

BACKGROUND

A 35-year-old ASA PS I lady was posted for total thyroidectomy under general anaesthesia with endotracheal intubation. Her lab values, thyroid hormone status, CXR, ECG, were normal. She did not have any history of bronchial asthma, hypertension or previous thyroid surgeries. She was premedicated prior to surgery with midazolam, fentanyl and glycopyrrolate IV. Standard monitors were attached and induced with propofol and vecuronium and intubated with flexometallic tube and maintained on 2%-3% sevoflurane. VCV was used for ventilation. Intraoperative period was uneventful. At the end of surgery, she was reversed, extubated and shifted to SICU for postoperative care. There, immediate postoperatively, she developed desaturation and hypotension. On examination, she was found to have surgical emphysema and was in respiratory distress and SpO2 was falling to below 80%, she was intubated immediately and shifted to operation theatre for re-exploration for suspected tracheal injury. On auscultation in OT, air entry was reduced on both sides, tension pneumothorax was suspected and confirmed by bedside USG and intercostal tube was inserted on both sides, the patient improved dramatically following that, neck was re-explored to rule out tracheal injury following thyroidectomy, was normal with no leak following saline flooding. The cause for bilateral pneumothorax was not clear as there was no tracheal injury on re-exploration and the dissection was limited to the neck during surgery and injury to the pleura was unlikely. Usual possible causes that lead to pneumothorax following thyroid surgery were pleural injury, ventilation problems or air tracking through fascial planes of the neck in deep dissections involving deep lymph nodes of the neck and third level fascia of the neck i.e. the prevertebral fascia and reaches the anterior mediastinum before bursting through the weak area in the lateral wall of mediastinal pleura into the thoracic cavity. Postoperative exaggerated respiratory efforts like bucking, coughing, laryngospasm, jet ventilation can also create more pressure gradients between atmosphere air and pleura and mediastinum and increase the chance of tracheal disruption especially in a background of tracheomalacia. Use of tracheal tube exchangers without proper care can also cause tracheal injury and pneumothorax in the postoperative period.

KEYWORDS

Pneumothorax, Post-thyroid Complications, Neck Surgery.

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