Size Does Matter

CASE OF THE MONTH

PRESENTED BY

THE THYROID SURGERY CENTER OF TEXAS, P.A.

1927 Lohmans Crossing Road, Suite 201, Austin, TX 78734

www.thyroidcancer.com

512-608-9595; Fax-512-608-9833

Size Does Matter

Now that I have your attention, this newsletter's patient is a 43 y/o lady from about 3 hours outside of Austin. In September of last year she was diagnosed in her hometown with Graves' Disease and placed on an unusually large dose of Propylthiouracil for months. Her symptoms improved, but in the three months prior to being seen here, her gland quickly and dramatically increased in size and she could almost not swallow and could barely breathe if lying down. Our main concern, aside from protecting the airway, was that this may have evolved into a thyroid lymphoma. Anaplastic carcinoma was briefly considered but soon dismissed as she was a bit young for this diagnosis and anaplastic cancer surely would have caused considerable local symptoms such as hemorrhage, hoarseness, or stridor. The diagnosis was moot from our perspective because this lady needed a thyroidectomy simply to continue breathing. Certainly, we would adapt the operation to the diagnosis on frozen section during her surgery. Thankfully, all was benign.

Preparation for surgery was very important here. First, she was actually a little hypothyroid as a result of her inordinate dose of PTU so this was reduced to get her back into euthyroid range. Next, a CT scan was ordered so the anesthesiologists could get a look at the anatomical location of her airway. Please keep in mind that CT scans are rarely needed or indicated for thyroid disease. This was an exception. Anesthesia recommended that we get the Cardiovascular team involved if endotracheal intubation were not possible and emergency tracheotomy were not feasible. So, in the OR we had everything set up for fiberoptic intubation, emergency tracheotomy and all the equipment and technicians necessary to put the patient on cardio-pulmonary bypass as a final rescue attempt should the airway get completely obstructed.

Well, the short story is that Anesthesia did a beautiful job with a difficult intubation, the cardiovascular folks ultimately weren't needed, and the patient underwent an uneventful total thyroidectomy as an out patient. She walked out of the hospital 18 hours post op breathing better than she had in years.

I look forward to the small thyroid tumors I'll be taking out next week, because you see, size does matter.

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