Case 2: Airway obstruction in advanced thyroid malignancy

Otolaryngology, head and neck

CASE SUMMARY A male patient in his late 50s was transferred to a tertiary centre with impending airways obstruction. A benign fine needle aspirate had clouded the clinical picture of a rapidly enlarging mass. Despite signs of significant airway obstruction, the patient was not seen by an ear, nose and throat surgeon for three days. When the airway was examined, a fixed vocal cord was found. Adrenaline nebulisation and intravenous (IV) dexamethasone were needed, however definitive airway securing was not performed until another four days had passed, now being one week after admission. With impending airway compromise, an urgent fibre-optic intubation, tracheostomy and attempted thyroidectomy were performed. Postoperatively, the patient was unable to be weaned from the ventilator. Pathology showed a malignant spindle cell tumour of the thyroid, and a CT scan of the chest had shown multiple metastatic deposits with evidence of pleural effusions. There had been a delay in reading a chest X-ray that showed possible evidence of metastatic disease. The patient was treated palliatively after surgery and passed away from respiratory failure.

DISCUSSION This case has several areas for consideration. A patient with an impending airway obstruction waited seven days for a definitive diagnosis and airway control. The final diagnosis was likely to be a form of anaplastic thyroid cancer for which no intervention would have helped, and the patient’s outcome may not have changed. However, if it was an aggressive thyroid cancer, then aggressive surgery and possibly radioactive iodine may have improved the situation. The definitive pathology report to clarify this was not available. The cause for postoperative respiratory failure is the other area of concern. Presumably due to the metastatic disease and pleural effusion, this may have been exacerbated by the delay in securing an airway. Admittedly, if it was anaplastic carcinoma, ultimately no intervention would have helped. Perioperatively, the tracheostomy was required, and this in itself did not cause the patient’s demise.

CLINICAL LESSONS This was an advanced thyroid malignancy likely to cause the patient’s death no matter what treatment was performed. Nevertheless, avoidable delays in management and diagnosis occurred.