Papillary carcinoma of the thyroid gland is the most common, accounting for 75% of all thyroid malignancies, and the most indolent with a survival rate of 98%. Usually it presents as hypoechoic nodules in the thyroid gland. It is very rare for papillary carcinoma to present with large neck mass compromising airway and invading surrounding tissues. These features are more characteristic of anaplastic thyroid carcinoma. There are many challenges in treating such patients. 1) Airway access to overcome obstruction. 2) Anesthesia concerns. 3) Surgical clearance (as there is soft tissue invasion). 4) Preservation of the recurrent laryngeal nerve. 5) Preserving parathyroids to prevent post-operative hypocalcaemia. 6) Hypopharyngeal and cervical oesophageal integrity and continuity.

1. Airway management is large thyroid tumors

2. Case Report
Airway management is large thyroid tumors5
Honey Ashok a,
*, Prerana Rao b
, Yedahalli Seetharama Nagamani b
a
Consultant & Co-ordinator, Department of ENT-Head & Neck Surgery, Apollo Hospitals, No 154/11,
Opposite Indian Institute of Management, Bannerghatta Road, Bangalore 560076, India
b
Registrar, Department of ENT-Head & Neck Surgery, Apollo Hospitals, No 154/11, Opposite Indian
Institute of Management, Bannerghatta Road, Bangalore 560076, India
a r t i c l e i n f o
Article history:
Received 2 January 2014
Accepted 12 February 2014
Available online xxx
Keywords:
Thyroid
Papillary
Airway
Tracheostomy
a b s t r a c t
Papillary Carcinomas of the thyroid are slow growing and least aggressive of all thyroid
tumors. These tumors when large can cause compression of the trachea and symptoms of
dyspnea and stridor. Airway management is of crucial importance not only for symp-
tomatic relief, but also for airway control pre-operatively till the definitive diagnosis and
treatment is planned. The dilemmas faced in airway management are many folds
considering the tumor profile and patient compliance. It plays a crucial role in final deci-
sion making. Papillary thyroid carcinoma prognosis is good. Distant metastasis is also not a
contraindication for treating the primary.
Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Papillary carcinoma of the thyroid gland is the most common,
accounting for 75% of all thyroid malignancies, and the most
indolent with a survival rate of 98%.1
Usually it presents as
hypoechoic nodules in the thyroid gland. It is very rare for
papillary carcinoma to present with large neck mass
compromising airway and invading surrounding tissues.
These features are more characteristic of anaplastic thyroid
carcinoma.
There are many challenges in treating such patients.
1) Airway access to overcome obstruction.
2) Anesthesia concerns.
3) Surgical clearance (as there is soft tissue invasion).
4) Preservation of the recurrent laryngeal nerve.
5) Preserving parathyroids to prevent post-operative
hypocalcaemia.
6) Hypopharyngeal and cervical oesophageal integrity and
continuity.
2. Case report
A 76-year-old male patient presented with stridor. He gives
history of neck swelling noticed since three years gradually
increasing in size, history of dysphagia and hoarseness of
voice since one year. Stridor is since one week. On examina-
tion there was a large swelling in front of the neck covering
5
This case has not been presented in any meeting. Planned for a poster presentation for the National Conference of Association of
Otolaryngologists of India (AOI) in January 2014, Mysore.
* Corresponding author. Tel.: þ91 (0) 9945510365; fax: þ91 (0) 8041463151.
E-mail addresses: oncosurg@yahoo.com, drhoneyashok@gmail.com (H. Ashok).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
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Please cite this article in press as: Ashok H, et al., Airway management is large thyroid tumors, Apollo Medicine (2014), http://
dx.doi.org/10.1016/j.apme.2014.02.002
http://dx.doi.org/10.1016/j.apme.2014.02.002
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

3. the whole neck measuring around 15 Â 18 cm in size, hard in
consistency, extending from the chin to the clavicle and to the
posterior triangle of the neck laterally. Patient was main-
taining saturation of 94% on room air, with persistent
tachypnea and restlessness. Patient was shifted to the ICU for
observation.
CT scan neck was done to ascertain the extent of the tumor
and assess the airway. CT scan showed a large tumor with ill-
defined margins due to infiltration into the soft tissue with
gross distortion of the airway starting from the oropharynx to
the lower cervical trachea, with marked narrowing and shift to
the left. The internal jugular vein on the left showed large
tumor thrombi occluding the whole length of the vein. The
common carotid artery and the internal and external carotid
were engulfed by the tumor with signs of infiltration (Figs. 1e6).
The immediate concern was to have access to the airway.
Awake fibre optic bronchoscopic intubation was done by
the pulmonologist, size 7 endotracheal tube was inserted.
FNA revealed Papillary carcinoma.
Planning the further course of action was tricky.
Getting a permanent accessible airway was difficult as we
couldn’t have retained the endotracheal tube for long as it
would get clogged with crusts and secretions even with the
stringent measures of cleaning, suctioning and nebulization.
Tracheostomy was difficult due to the size of the tumor. Even
if we had gone through the tumor for the tracheostomy,
retaining a patent tracheostoma through the tumor would be
difficult due to tumor bleed, tumor extending into the stoma
and blocking it, accidental displacement of tube making it
unsafe and changing the tracheostomy tube would be diffi-
cult. Have a safe tracheostoma was the first priority.
The tumor was inoperable considering the extent of the
disease and the possibility of distant metastasis. Metastatic
work up was not possible considering the intubated status of
the patient and considering the extent of the primary disease
it was likely that he had distant metastasis. Also it was not
worth taking the risk of shifting the patient as the disease
being papillary carcinoma distant metastasis wouldn’t alter
the plan of treatment.
Given the grim circumstances the relatives were explained
about the diagnosis and status of the patient and the treat-
ment options and the chances of survival.
In 2 days of intubation patient was taken up for surgery. On
table the anesthetist felt resistance in ventilating and there
was sudden drop in oxygenation. Urgent tracheostomy was
done through a lateral approach where the trachea was the
most superficial considering the size of the tumor. The airway
was secured with no hypoxia damage to the patient, trache-
ostomy tube was fixed with stay sutures to prevent accidental
dislodgement.
Fig. 1 e Pre-operative.
Fig. 2 e Per-operative photo showing infiltration of the
carotids.
Fig. 3 e CT scan neck sagittal view.
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4. On exposure the tumor was found to infiltrate the strap
muscles, sternocleidomastoid, the prevertebral muscles, ca-
rotid sheath, common e external and internal carotid arteries
were thickened and involved by the tumor which was shaved
from the adventitia, external carotid was ligated. Laryngeal
framework, trachea and pharynx also showed infiltration.
Post-operative large dose scan with ablation done with I
131 was given. There were multiple metastatic foci in the
lungs and bones. Patient is on Ryle’s tube feeds and on tra-
cheostomy. Right vocal cord is fixed and left is mobile, with
phonatory gap and minimal aspiration.
3. Discussion
Papillary carcinomas rarely causes respiratory distress as they
are slow growing. Anaplastic carcinomas usually are fast
growing and cause infiltration into the surrounding structures
causing respiratory symptoms and airway access and main-
tenance becomes difficult.2
Airway management for these
patients depend on the extent of distant disease and the
family’s understanding of the advanced nature of the disease
and the palliative efforts. Decision regarding active manage-
ment depends on tumor factors like pathology, staging, sur-
vival rate and overall prognosis.
Conflicts of interest
All authors have none to declare.
Acknowledgment
We would like to acknowledge Dr Chandrashekar’s contribu-
tion in managing the case.
r e f e r e n c e s
1. Revised American Thyroid Association Management
Guidelines for patients with thyroid nodules and differentiated
thyroid cancer. Thyroid. 2009;19.
2. Shaha AR. Airway management in anaplastic thyroid
carcinoma. Laryngoscope. 2008 Jul;118:1195e1198.
Fig. 4 e CT scan coronal view.
Fig. 5 e Post-operative.
Fig. 6 e Tracheostomy.
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