Routine Chest X-Ray Prior to Thyroid Surgery: Is It Always Necessary?

Article · August 2012with66 Reads
DOI: 10.1007/s00268-012-1720-z · Source: PubMed
Abstract
Despite lack of evidence-based support, chest X-ray (CXR) prior to thyroid surgery is often used to identify tracheal deviation that may predict difficulty with intubation. The aim of this study is to establish the utility of preoperative CXR to assess tracheal deviation in this group of patients. We analyzed a prospective database of 1,000 consecutive patients who underwent thyroid surgery. Patients' charts were reviewed for demographic data, CXR readings, other imaging findings, anesthesia records, and pathology findings. Patients with tracheal deviation (TD) on CXR were compared to patients without (no TD). Six hundred eighty-nine (69 %) patients had a CXR performed prior to surgery. TD was identified in 252 (37 %) patients while 437 (63 %) did not have TD. The two groups did not significantly differ in mean age, BMI, or gender. Patients with TD on CXR had larger thyroid glands (51 ± 4 vs. 28 ± 2 g, p < 0.001) and reported a higher rate of tracheal compressive symptoms (19 vs. 12 %, p = 0.005). However, this did not translate into more difficult intubations as reported by the anesthesiologist (5 vs. 7 %, p = 0.31) or more intubation attempts (1.2 ± 0 vs. 1.1 ± 0, p = 0.1). Lung findings on CXR that resulted in further workup were identified in 32 (5 %) patients, with additional pathology found in only 6 (1 %) patients. There is no correlation between a finding of tracheal deviation on preoperative CXR and difficult intubation in thyroid patients. Therefore, CXR for the sole purpose of identifying tracheal deviation in thyroid surgery candidates is not warranted.
1 23
World Journal of Surgery
Official Journal of the International
Society of Surgery/Société
Internationale de Chirurgie
ISSN 0364-2313
World J Surg
DOI 10.1007/s00268-012-1720-z
Routine Chest X-Ray Prior to Thyroid
Surgery: Is It Always Necessary?
Brian W.Hong, Haggi Mazeh, Herbert
Chen & Rebecca S.Sippel
1 23
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Routine Chest X-Ray Prior to Thyroid Surgery: Is It Always
Necessary?
Brian W. Hong Haggi Mazeh Herbert Chen
Rebecca S. Sippel
ÓSocie
´te
´Internationale de Chirurgie 2012
Abstract
Background Despite lack of evidence-based support,
chest X-ray (CXR) prior to thyroid surgery is often used to
identify tracheal deviation that may predict difficulty with
intubation. The aim of this study is to establish the utility of
preoperative CXR to assess tracheal deviation in this group
of patients.
Methods We analyzed a prospective database of 1,000
consecutive patients who underwent thyroid surgery.
Patients’ charts were reviewed for demographic data, CXR
readings, other imaging findings, anesthesia records, and
pathology findings. Patients with tracheal deviation (TD)
on CXR were compared to patients without (no TD).
Results Six hundred eighty-nine (69 %) patients had a
CXR performed prior to surgery. TD was identified in 252
(37 %) patients while 437 (63 %) did not have TD. The
two groups did not significantly differ in mean age, BMI,
or gender. Patients with TD on CXR had larger thyroid
glands (51 ±4 vs. 28 ±2g,p\0.001) and reported a
higher rate of tracheal compressive symptoms (19 vs.
12 %, p=0.005). However, this did not translate into
more difficult intubations as reported by the anesthesiolo-
gist (5 vs. 7 %, p=0.31) or more intubation attempts
(1.2 ±0 vs. 1.1 ±0, p=0.1). Lung findings on CXR that
resulted in further workup were identified in 32 (5 %)
patients, with additional pathology found in only 6 (1 %)
patients.
Conclusion There is no correlation between a finding of
tracheal deviation on preoperative CXR and difficult intu-
bation in thyroid patients. Therefore, CXR for the sole
purpose of identifying tracheal deviation in thyroid surgery
candidates is not warranted.
Introduction
The chest X-ray (CXR) is the most commonly performed
radiographic exam and constitutes approximately 45 % of
all radiographic exams [1]. Over 150,000,000 CXRs are
done yearly in the U.S. at a cost of over 11 billion dollars
[2,3]. Although the dose of radiation from a CXR is very
small (0.25 mRad), this imaging modality should be per-
formed only when indicated [1,4]. Preoperative screening
CXR studies continue to be used widely despite the high
cost and reported low yield [5]. Most physicians now use
‘clinical judgment’’ to mitigate the frequency of the CXR.
The role of the CXR prior to thyroid surgery has been
influenced by concerns for the presence of upper-airway
changes that may be caused by the thyroid pathology. Such
changes include deviation, compression, tumor infiltration
of the trachea, laryngeal nerve dysfunction, laryngeal
edema, and tracheomalacia [6,7]. Tracheal deviation seen
on CXR has been seen in up to 25 % of surgically treated
goiters [8]. How this information is utilized by anesthesi-
ologists to predict difficulty in airway management is not
fully standardized.
Management of a difficult airway in general surgery has
been well studied and there are several algorithms that have
been developed to deal with this issue [9]. However, there
have been only a few studies that analyzed the factors
associated with the difficulty in endotracheal intubation in
patients undergoing thyroid surgery [1013]. These studies
Brian W. Hong and Haggi Mazeh contributed equally to this work.
B. W. Hong H. Mazeh (&)H. Chen R. S. Sippel
Section of Endocrine Surgery, Department of Surgery,
University of Wisconsin, K3/704 Clinical Science Center,
600 Highland Avenue, Madison, WI 53792, USA
e-mail: mazeh@surgery.wisc.edu
123
World J Surg
DOI 10.1007/s00268-012-1720-z
Author's personal copy
are varied in their size and methodology. There have been
mixed results on the factors associated with difficult
endotracheal intubation in patients undergoing thyroid
surgery, looking at malignancy, size of the thyroid, body
mass index (BMI), tracheal deviation, or compression [6,
11]. In addition, there is a paucity of data about what
factors are predictive of a difficult airway during intubation
for thyroid surgery. Because failed intubation attempts can
increase morbidity and mortality in these patients, there is a
need to predict which patients may be difficult to intubate
[4]. To date, no study has shown the correlation between
preoperative CXR findings and intubation difficulties in
thyroid surgery. The aim of this study was to present our
experience with CXRs performed prior to thyroid surgery
in a large cohort at a single institution and to assess the
correlation between a finding of tracheal deviation on
preoperative CXR and difficult endotracheal intubation.
Methods
A review was performed of the Prospective Thyroid Sur-
gery Database of all patients who underwent thyroid sur-
gery at the University of Wisconsin. Between January 2004
and December 2009, there were a total of 1,000 patients
who had thyroid surgery. Patients who underwent any
thyroid resection, i.e., total thyroidectomy, thyroid lobec-
tomy, and completion thyroidectomy, were included in the
study.
Data on patients’ demographics, CXR readings, ultra-
sound findings, CT scan findings, anesthesia records, clinic
notes, and pathology findings were prospectively collected
and retrospectively verified by review of the medical
record. Specific attention was paid to patients’ complaints
of tracheal or esophageal compression symptoms that
included stridor, shortness of breath, vague sensation of
pressure, difficulty breathing when lying down, voice
changes, persistent cough, and dyspnea on exertion, dys-
phagia, and a subjective feeling that ‘‘food is stuck.’
Presence of tracheal deviation on CXR and indication for
surgery were noted. The presence of a multinodular goiter
(MNG) was based on preoperative ultrasound findings. The
presence of malignancy, gland size, and final pathology
were documented as per the final pathology report. The
anesthesia records for these patients were retrospectively
reviewed. Data extracted included BMI, Mallampati score,
number of intubation attempts, and any other relevant
notes. At our institution fiberoptic intubation was used in
three scenarios: difficult intubation after failure to intubate
with a laryngoscope, elective (prophylactic) for patients
with anticipated difficult intubation, and elective as a
teaching tool for anesthesiology residents who are on their
airway rotation. We could not differentiate between the
two last scenarios and these were therefore entitled
‘elective fiberoptic intubation.’’ The anesthesiologist’s
rating of whether the intubation was easy (EI) or difficult
(DI) was also recorded. In addition, abnormalities that
prompted further workup based on the preoperative CXR
were identified and any subsequent pathology was noted.
As the study was performed in a teaching university hos-
pital, there was no anesthesia provider selection. All intu-
bations were performed by anesthesia residents or CRNAs
with the guidance and assistance of an attending anesthe-
siologist. The preoperative findings did not influence this
protocol.
Initial comparison was performed between patients who
had a preoperative CXR and those who did not. We then
compared patients who had tracheal deviation (TD) on
CXR with those without TD. Lastly, we compared patients
with difficult intubation with those without (Fig. 1). All
variables were compared for all subgroups.
To identify differences between the subgroups, univar-
iate analyses with the t-test and the v
2
test were performed.
Statistical calculations were completed using statistical
software SPSS ver. 20 (SPSS, Inc., Chicago, IL), and
p\0.05 was considered to represent statistical signifi-
cance for all comparisons.
Results
Over the course of the 5 years studied there were 1,000
thyroid surgeries conducted at the University of Wisconsin.
The mean age of the entire cohort was 50 ±1 years, 80 %
were females, and the mean BMI was 33 ±5 kg/m
2
.
Tracheal and esophageal compressive symptoms were
documented in 13 and 20 % of the patients, respectively.
Multinodular goiter was noted in 11 % of the patients,
malignancy was present in 32 %, and total thyroidectomy
was performed in 52 %. The mean gland weight was
36 ±2 g. The mean Mallampati score was 1.6 ±0 and
fiberoptic intubation was used in 11 % of the cases. Dif-
ficult intubation as defined by the anesthesiologist was
noted in only 6 % of the cases.
Preoperative CXR was performed in 689 (69 %) of the
patients. Comparison between patients who had preopera-
tive CXR to those who did not is detailed in Table 1. The
two subgroups did not differ in multiple variables: age,
gender, BMI, procedure performed, presence of MNG,
gland size and weight, presence of malignancy, or com-
pressive symptoms. The two groups also had similar mean
Mallampati scores, number of intubation attempts, use of a
fiberoptic scope, or documented difficult intubation
(Table 1).
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Of the patients who had a preoperative CXR, 252
(37 %) had documented tracheal deviation. The compari-
son between patients with and without TD is detailed in
Table 2. The groups were not significantly different for
age, gender, BMI, and the procedure performed. Patients
with TD had larger glands as reflected by lobe size and
gland weight, and the rate of benign disease was higher in
this group. As expected, these patients also had a higher
incidence of documented complaints of tracheal compres-
sion symptoms (19 vs. 12 %, p=0.005). Fiberoptic intu-
bation was used more commonly in patients with TD (13
vs. 8 %, p=0.02); however, the rate of elective use of
fiberoptic intubation was not different between the groups
(8 vs. 6 %, p=0.27). All of the patients with a conversion
to fiberoptic intubation were listed as difficult intubation.
Surprisingly, patients with TD had a similar number of
intubation attempts as those without TD (1.2 ±0 vs.
1.1 ±0, p=0.10), and, more importantly, the rate of
difficult intubation was not significantly different (5 vs.
7%,p=0.31) (Fig. 1).
Of the entire cohort, only 6 % had difficult intubation as
reported by the anesthesiologist. Comparison of the difficult
(DI) and easy intubation (EI) groups showed that the factors
associated with difficult intubation were mean Mallampati
score (2.2 ±0vs.1.6±0, p\0.001), and multinodular
goiter (17 vs. 8 %, p=0.02). Other factors considered such as
the presence of compressive symptoms (22 % with DI vs. 19 %
with EI, p=0.58), age (50 ±1vs.53±1years,p=0.23),
BMI (34 ±1vs.34±4kg/m
2
,p=0.99), thyroid malig-
nancy (24 vs. 34 %, p=0.14), and gland weight (46 ±6vs.
36 ±1g,p=0.09) were not associated with difficult endo-
tracheal intubation. Table 3summarizes the differences
between patients with and without difficult intubation. Patients
with difficult intubation were older, more commonly males, had
larger glands, and more commonly complained about tracheal
compressive symptoms. Interestingly, tracheal deviation in
patients with preoperative CXR was not associated with diffi-
cult intubation (45 vs. 37 %, p=0.27).
Lung findings on CXR that resulted in further workup
were identified in 32 (5 %) patients. This resulted in per-
forming a follow-up computed tomography (CT) scan of
the chest in 28 (88 %) patients. In those patients who did
not have a subsequent CT scan, two were shown to have
old granulomatous disease, one underwent a repeat CXR
and the abnormality was shown to be a shadow, and one
had a stable lung nodule in comparison to a previous CXR.
On subsequent workup, additional pathology was found in
only six (1 %) patients (tuberculosis, pulmonary fibrosis in
two patients, pleural cyst, metastatic thyroid cancer, and
lymphoma).
Table 1 Comparison between
patients who had preoperative
chest X-ray with those who did
not
CXR chest X-ray, BMI body
mass index, MNG multinodular
goiter
Variable No CXR (N=311) CXR (N=689) pvalue
Mean age (years) 50 ±150±1 0.99
Mean BMI (kg/m
2
)30±134±2 0.39
Gender (% females) 77 76 0.77
Procedure (% total thyroidectomy) 47 53 0.11
MNG (%) 8 12 0.42
Size of right lobe (cm) 5.2 ±0.1 5.2 ±0.1 0.50
Size of left lobe (cm) 5.0 ±0.1 5.0 ±0.1 0.80
Gland weight (g) 36 ±336±2 0.93
Malignancy (%) 30 32 0.41
Tracheal compressive symptoms (%) 12 12 0.98
Esophageal compressive symptoms (%) 17 20 0.19
Mean Mallampati score 1.6 ±0 1.7 ±0 0.70
Mean number of intubation attempts 1.1 ±0 1.1 ±0 0.67
Use of fiberoptic (%) 13 10 0.16
Difficult intubation (%) 4 6 0.27
1,000
Thyroidectomies
No Chest X-Ray
(N=311)
Chest X-Ray
(N=689)
Tracheal Deviation
(N=252)
No Tracheal Deviation
(N=437)
Difficult Intubation
(N=13, 6%)
Difficult Intubation
(N=12, 5%)
Difficult Intubation
(N=29, 7%)
Fig. 1 Study flowchart and the rates of tracheal deviation and
difficult intubation in each subgroup
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Discussion
At the University of Wisconsin, preoperative CXR is per-
formed for a variety of reasons, including identification of
occult lung disease, masses, or other potential concerns
related to specific populations (i.e., older patients, patients
with known coexisting lung or cardiac disease, history of
smoking or cancer). In addition to these indications, a
preoperative CXR is routinely obtained in patients with
thyroid enlargement or nodular disease prior to surgery in
order to assess for tracheal deviation. The practice of
routine preoperative CXR for all nonpulmonary or thoracic
surgical candidates has been questioned in recent years due
to concerns of unnecessary radiation and health-care costs
[5,14,15]. The trend of minimizing the number of routine
CXRs has not been implemented for thyroid surgery due to
traditional concerns regarding the possibility of endotra-
cheal intubation difficulties in the presence of thyroid
pathologies [16]. It is true that certain rare pathologies such
as calcifications and soft tissue neck masses may be iden-
tified on the CXR of thyroid surgery candidates, but the
advocates for routine CXR rely mostly on the assumption
Table 2 Comparison between
patients who had tracheal
deviation (TD) on preoperative
chest X-ray with those who did
not
TD tracheal deviation, BMI
body mass index, CXR chest
X-ray, MNG multinodular goiter
Variable No TD (N=437) TD (N=252) pvalue
Mean age (years) 50 ±150±1 0.85
Mean BMI (kg/m
2
)30±134±2 0.39
Gender (% females) 77 81 0.17
Procedure (% total thyroidectomy) 55 50 0.10
MNG (%) 13 12 0.65
Size of right lobe (cm) 5.1 ±0.1 5.6 ±0.1 0.001
Size of left lobe (cm) 4.9 ±0.1 5.4 ±0.1 0.001
Gland weight (g) 28 ±251±4\0.001
Malignancy (%) 36 27 0.03
Tracheal compressive symptoms (%) 12 19 0.005
Esophageal compressive symptoms (%) 20 22 0.45
Mean Mallampati score 1.7 ±0 1.6 ±0 0.31
Mean number of intubation attempts 1.1 ±0 1.2 ±0 0.10
Use of fiberoptic (%) 8 13 0.02
Elective use of fiberoptic (%) 6 8 0.27
Difficult intubation (%) 7 5 0.31
Other CXR findings (%) 9 7 0.28
Table 3 Comparison between
patients who had difficult
intubation (DI) with those who
did not
DI difficult intubation, BMI
body mass index, CXR chest
X-ray, MNG multinodular goiter
Variable DI (N=53) No DI (N=636) pvalue
Mean age (years) 56 ±150±1 0.003
Mean BMI (kg/m
2
)33±134±5 0.96
Gender (% females) 64 79 0.01
Procedure (% total thyroidectomy) 66 53 0.07
MNG (%) 43 30 0.05
Size of right lobe (cm) 5.5 ±0.2 5.1 ±0.4 0.01
Size of left lobe (cm) 6.1 ±0.4 4.9 ±0.4 0.02
Gland weight (g) 57 ±835±4 0.002
Malignancy (%) 25 33 0.17
Tracheal compressive symptoms (%) 25 14 0.04
Esophageal compressive symptoms (%) 19 21 0.76
Mean Mallampati score 2.3 ±0.1 1.6 ±0.1 \0.0001
Mean number of intubation attempts 2.0 ±0.1 1 ±0.1 \0.0001
Use of fiberoptic (%) 37 8 \0.0001
Tracheal deviation (%) 45 37 0.23
Other CXR findings (%) 8 8 0.85
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that the presence of tracheal deviation may predict endo-
tracheal intubation difficulties [17]. This is evident by the
anesthesiologist’s CXR reading that specifically focuses on
the trachea’s location in the neck. In this study we
reviewed a cohort of 1,000 patients who underwent thyroid
surgery and our main finding was that tracheal deviation on
preoperative CXR was not associated with difficult intu-
bation. Similar to other studies, tracheal deviation was
identified in 37 % of the patients. As expected, patients
with tracheal deviation had a larger and heavier gland as
well as a higher incidence of tracheal compression symp-
toms. While the differences in size are statistically signif-
icant because of the large sample size, the actual difference
is only 5 mm, which is unlikely to be clinically meaning-
ful. Fiberoptic techniques for intubation were used more
frequently in patients with tracheal deviation; however,
there was no significant difference in the rate of elective
fiberoptic intubations. This study was conducted at a
teaching university hospital where the fiberoptic scope is
occasionally used for teaching purposes; this may con-
tribute to the use of this technique in cases where there is a
low suspicion for difficult intubation. Nonetheless, the rate
of difficult intubations as recorded by the anesthesiologist
was not different between patients with and without tra-
cheal deviation.
In a study by McHenry and Piotrowski [6] of 91 patients
who underwent thyroidectomy, it was shown that marked
thyroid enlargement and upper-airway compression are
caused predominantly by benign disease. Similarly, in our
study we showed that there was a higher rate of benign
disease in those with TD on preoperative CXR. In accor-
dance with our study, they also demonstrated that radio-
graphic imaging of the neck does not alter anesthesia
management and that fiberoptic intubation in patients with
tracheal compression is not routinely indicated [6]. In a
study by Voagis and Kyriakis [12] that looked at 4,742
intubations for general surgery, thyroid goiter was associ-
ated with difficulty in intubation (7 % for patients with
goiter versus 1 % in patients without goiter). In a subgroup
of 321 patients with goiter, they also looked at the role of
tracheal deviation on preoperative imaging and found that
TD on CXR was predictive of though not invariably
associated with difficult intubation [12]. This is opposite of
our results.
Previous studies have looked at the factors that affect
intubation in thyroid surgery patients. In a study done by
Bouaggad et al. [11], 320 patients who underwent thyroid
surgery were analyzed for factors associated with difficult
intubation and it was found that cancerous goiters were
associated with difficult intubation. However, their study
failed to demonstrate an association between goiter size
and difficult intubation. In our study, neither carcinoma on
pathology nor gland weight was associated with difficult
intubation. In contrast, in a study by Randolph et al. [10]of
200 patients who underwent thyroidectomy, goiter size and
bilateral goiter were associated with difficult intubation,
though their rate of difficult intubation was only 2 %.
Routine preoperative CXR may be justified by the rate
of incidental findings that may lead to further evaluation of
significant pathologies. Our study suggests that this is not
the case. Only 5 % had incidental lung findings that were
further evaluated. Additional pathology was identified in
only six (1 %) patients and disease requiring treatment or
management adjustment was found in only 3 (0.5 %)
patients (tuberculosis, lymphoma, and metastatic thyroid
cancer). This corresponds to other studies that do not jus-
tify CXR as a screening tool. As only 1.8 % of our patients
had a CT scan because it is not routinely ordered to assess
tracheal deviation in thyroid patients, we could not com-
ment on its utility in this setting.
There is a cost for routine CXRs, both monetary and in
terms of radiation exposure [13]. Based on the results of
our study, the finding of TD on a preoperative CXR does
not mean that intubation will be difficult during thyroid
surgery. In addition, in this study 31 % of the patients did
not have a preoperative CXR. This group was not signifi-
cantly different than those who had a preoperative CXR in
any of the variables measured, including the incidence of
difficult intubation. This may suggest that routine CXR
prior to thyroid surgery is unnecessary.
It is not our intent to suggest that preoperative imaging
of the neck is never indicated. Certainly, there are many
different indications for preoperative CXR or CT scan of
the neck and the choice of imaging studies must be tailored
to each patient. Patients with known lung disease, cardiac
disease, and a history of smoking or cancer may have an
indication for preoperative chest imaging irrespective of
their thyroid disease. Although not investigated in this
study, it is possible that CT scans are more appropriate for
the evaluation of tracheal narrowing and degree of devia-
tion in patients with large goiters. Our data suggest only
that routine CXR is not valuable solely for identifying
tracheal deviation before thyroid surgery.
This study has several limitations. It is a single-institu-
tion retrospective study and as such is prone to bias despite
the large number of patients included. A prospective study
is unlikely to be performed as hospitals adhere to guide-
lines regarding preoperative studies required for patients
undergoing surgery. As tracheal deviation is not graded by
the radiology report and as the anesthesiologists also doc-
ument it as an all-or-nothing phenomenon, we have chosen
to adhere to this concept. We could not isolate the exact
indication for preoperative CXR in each patient. Some
CXR were certainly ordered for additional indications
other than the presence of tracheal deviation. Nevertheless,
it was not the purpose of this study to dispute other
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indications for preoperative CXR and therefore these
indications were not investigated. The anesthesia records
were retrospectively reviewed and the reasons for choosing
fiberoptic intubation were not available. Thus, it is not clear
why fiberoptic intubation was more common in patients
with TD even though the percent of difficult intubations
was not significantly different from that of patients without
TD. However, it may be that the presence of TD on CXR
led the anesthesiologist to do more fiberoptic intubations,
even if they were not necessarily required. It is possible
that some of the elective fiberoptic intubations ‘‘prevented’’
difficult intubation. Nevertheless, even if we added all
elective fiberoptic intubations to the difficult intubations in
each group, the rates of difficult intubation would be
similar (13.8 vs. 13.4 %, p=0.71). It may be that some of
the patients had difficult intubation for reasons not related
to their thyroid mass and this could not be isolated. The
large cohort may compensate for such bias between the
groups. Lastly, our current anesthesia records define intu-
bation difficulty as binary: difficult or easy. Perhaps a
scaled grading of the difficulty would be a better tool for
assessing the intubation process in future studies.
Conclusions
Though tracheal deviation in patients with thyroid disease
is associated with larger goiters and compressive symp-
toms, this finding on CXR is not associated with difficulty
with intubation, nor is it associated with more intubation
attempts. Hence, routine preoperative CXR for airway
assessment is not indicated as it does not seem to provide
meaningful information to aid in airway management in
patients undergoing thyroid surgery.
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  • [Show abstract] [Hide abstract] ABSTRACT: The objective was to determine patient and gland characteristics associated with difficult intubation in patients undergoing thyroidectomy for goiter and to assess different methods of intubation in these patients. This study was an IRB-approved, retrospective chart review of 112 consecutive patients undergoing hemithyroidectomy or total thyroidectomy for thyroid goiter from 2009-2012 at an academic tertiary care facility in Bronx, New York. Patient demographics, thyroid gland characteristics (gland weight and nodule size), presence of preoperative symptoms (dyspnea, dysphagia, and hoarseness), and radiographical findings (tracheal compression, tracheal deviation, and substernal extension of the thyroid gland) were recorded. Anesthesia records were reviewed for method of intubation, as well as success or failure of intubation attempts. Nineteen patients (17.0%) were men and 93 (83.0%) were women. The age of the patients included in the study ranged from 14 to 86 years with a mean ± SD age of 53.5 ± 14.7 years. Difficult intubation was noted with 13 (11.6%) patients. Only patient age was significantly associated with difficult intubation. The mean age of patients with airway difficulty was 60.7 ± 3.7 years compared to 52.1 ± 1.5 years in those who did not experience airway difficulty (P = .04). No other reviewed risk factors were found to be significantly associated with difficult intubation. Fiberoptic intubation (FOI) was used in 38 patients and difficult intubation occurred in 18.4% (7/38). Direct laryngoscopy with transoral intubation (LTOI) was used in 58 patients, in whom 3.4% (2/58) experienced a difficult intubation. FOI was aborted 6 times and LTOI was subsequently successful in each of these cases. Our results suggest that benign nodular goiter disease does not pose significant challenges to intubation in our patient cohort. The technique of intubation deviated from the initial plan several times in the FOI group, whereas LTOI was ultimately successful in every case. Our data suggest that the role of fiberoptic intubation for patients with large goiters should be further refined.
    Article · Mar 2014
  • [Show abstract] [Hide abstract] ABSTRACT: In this systematic review, we investigated the effects of goitre and its treatment on the trachea and the oesophagus. A total of 6355 papers were screened in scientific databases, which disclosed 40 original studies (nine descriptive and 31 interventional). Although most studies are hampered by a number of methodological shortcomings, it is uncontested that goitre affects the trachea as well as the oesophagus in a large proportion of people. This leads to upper airway obstruction, swallowing dysfunction, or both, which may remain undisclosed unless specifically investigated for. Assessment of the tracheal dimensions should be done by magnetic resonance imaging or computed tomography, and detection of upper airway obstruction by flow volume loops, with focus on the inspiratory component. A clinical evaluation of the oesophageal function is difficult to implement and could be replaced by available and validated questionnaires on swallowing. Although radioiodine therapy and thyroidectomy relieve the negative effect of goitre on the trachea and the oesophagus, many issues remain unexplored.
    Article · Aug 2014
  • Full-text · Conference Paper · Oct 2014 · Journal of thoracic imaging
  • [Show abstract] [Hide abstract] ABSTRACT: INTRODUCTION.Ruptured abdominal aortic aneurysm (AAA) is a life-threatening condition with an overall mortality rate of 65%. Massive haemorrhage requires infusion of fluids that do not contain clotting factors which develops dilutional coagulopathy. Rotational thrombelastometry (ROTEM) permits differential diagnosis of the underlying pathomechanism of coagulopathy. PCC showed much efficiency in the treatment of intraoperative massive bleeding . CASE REPORT. A 79-year-old man was addmited to Vascular Surgery Department, Clinical center in Nis as an emergency with the symptoms of AAA rupture. After resuscitation he was trasported to the operation room (Hgb: 45 g/L, HCT: 15%, BP: 80/40 mmHg). Massive infusion of crystalloids, colloids and plasma expanders kept the patient hemodinamically stable but led to dilutional coagulopathy. Transfusion of platelets, cryoprecipitate and fresh-frozen plasma (FFP) were provided together with tranexamic acid. Total blood loss during the surgery was 5L and 1.85L was returned to the patient by autotransfusion. Coagulation status was checked by ROTEM. The greatest deviation was found in the INTEM, CFT=3374s and α=12o (Picture 1) and in the EXTEM, CFT=169s and α=66o (Picture 2). After the infusion of 500IJ PCC, the results of INTEM went back to normal ranges (CFT=71s, α=76o) (Picture 3), as well as the results of EXTEM (CFT=71s, α=77o) (Picture 4). After the extensive operation, the patient spend 5 days in the Intensive care unit and was discharget from hospital after 26 days. CONCLUSION. PCC improves coagulation stability faster and more efficient than FFP without the risk of transfusion, volume load and infectious complications.
    Full-text · Conference Paper · Oct 2014 · Journal of thoracic imaging
  • [Show abstract] [Hide abstract] ABSTRACT: A compartmental approach to the diagnosis of the mediastinal masses in children and adults has been widely used to facilitate the diagnosis and planning of diagnostic interventions and surgical treatment for many years. Recently, a new computed tomography-based mediastinal division scheme, approved by the International Thymic Malignancy Interest Group, has received considerable attention as a potential new standard. In this review article, this new computed tomography-based mediastinal division scheme is described and illustrated. In addition, currently used imaging modalities and techniques, practical imaging algorithm of evaluating mediastinal masses, and characteristic imaging findings of various mediastinal masses that occur in children and adults are discussed. Such up-to-date knowledge has the potential to facilitate better understanding of mediastinal masses in both pediatric and adult populations.
    Article · Jul 2015
  • [Show abstract] [Hide abstract] ABSTRACT: Difficult tracheal intubation (DI) is more common in thyroid than in other surgical branches due to thyromegaly. Proper preoperative airway evaluation is necessary in order to reduce the potential numerous complications. The study examined the incidence of DI in thyroid surgery and the influence of tracheal dislocation and other risk factors on DI. A prospective study was conducted on 2379 patients who underwent thyroidectomy at the Center for Endocrine Surgery, Clinical Center of Serbia, from 2007 to 2012. Patients were divided into groups with (n=162) and without DI (n=2217). Besides tracheal dislocation, another 13 risk factors contained in 13 screening tests and three additional factors of gender, age and diagnosis were defined. The incidence of DI in our study was 6.81%. The presence of tracheal dislocation was statistically significant, but not an independent predictor of DI. The diagnosis, large circumference and small neck length, previous DI, recessive mandible, tooth characteristics and oral anomalies were the most significant and independent predictors of DI. Neck circumference and small neck length had highest sensitivity. Previous DI had highest specificity. Thyromegaly, if causing tracheal dislocation and/or stenosis, represents a significant DI predictor, not individually, but in combination with other factors.
    Article · Mar 2016 · Journal of thoracic imaging
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May 1988 · Khirurgiia
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    August 1996 · American Journal of Surgical Pathology · Impact Factor: 5.15
      A review of 92 consecutive cases of papillary thyroid carcinoma diagnosed at The Methodist Hospital revealed 11 tall cell variant (TCV) cases in nine women and two men. There was a greater average age and larger tumor diameter of TCV cases compared with papillary thyroid carcinoma of the usual type (UPTC), but these differences were not statistically significant. Extrathyroidal extension of... [Show full abstract]
      Article
      January 1993 · Practica Otologica, Supplement
        We report two rare cases of thyroglossal duct cysts in the thyroid glands among 12 cases of thyroglossal duct cyst treated at our clinic in the last 7 years. One hundred thirty nine cases from the literature of the recent 10 years were reviewed. In both cases, cysts were seen in the right lobe of the thyroid gland, and the patients underwent partial thyroidectomy. Macroscopically, cystic... [Show full abstract]
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        January 2015 · Archiv für Klinische und Experimentelle Ohren- Nasen- und Kehlkopfheilkunde · Impact Factor: 1.55
          A globus sensation is one of the most common complaints in otolaryngologic clinics, and laryngopharyngeal reflux is the most common cause. However, thyroid nodules also can cause globus symptoms. The purpose of this study was to identify the characteristics of thyroid nodules that cause globus. We selected patients prospectively with a single thyroid nodule on ultrasonograms. Patients with... [Show full abstract]
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