Case 1: Airway obstruction – delay to diagnosis and airway control

Otolaryngology head and neck

CASE SUMMARY A man in his late-50s was transferred to a tertiary centre with impending airway 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 ENT (ear, nose and throat) surgeon for 3 days following admission, after which the airway was examined and a fixed vocal cord observed. Definitive airway securing was not performed until a week after admission, despite the patient needing adrenaline nebulisation and intravenous (IV) dexamethasone. Delayed reading of a chest X-ray indicated possible metastatic disease. One week following admission, with impending airway compromise, an urgent fibreoptic intubation, tracheostomy and attempted thyroidectomy was performed. Following the operation, the patient was unable to be weaned from the ventilator. Pathology showed a malignant spindle cell tumour of the thyroid. A computed tomography (CT) scan of the chest revealed multiple metastatic deposits with evidence of pleural effusions. Treatment shifted to palliative care, and the patient eventually passed away from respiratory failure.

DISCUSSION Despite the final diagnosis likely to be a form of anaplastic thyroid cancer for which the outcome may not have changed, there were clear issues in the management of this patient. Areas for consideration include: • A delay of 7 days for a definitive diagnosis and airway control for a patient with impending airway obstruction. • Provision of a definitive pathology report to clarify treatment. For an aggressive thyroid cancer, aggressive surgery and possibly radioactive iodine may have improved the situation. For an anaplastic carcinoma, no intervention would have helped. • Delay in securing the airway may have exacerbated the postoperative respiratory failure, presumably caused by the metastatic disease and pleural effusion. Again, if it was anaplastic carcinoma, no intervention would have helped.

CLINICAL LESSONS Delay in management and diagnosis compromised treatment for this patient with an advanced thyroid malignancy.