Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre

Retrosternal goitre (RSG) is an uncommon problem encountered rarely by anaesthetists working outside specialized head and neck (H&N) surgical units. Traditional anaesthetic teaching warns of difficult airway management in these patients. The incidence and extent of these problems is unclear.

We have performed a retrospective review of the anaesthetic management all patients with massive RSG (extending to the aortic arch or beyond) presenting for thyroidectomy at University Hospital Aintree from January 2007 to May 2012.

Five hundred and seventy-three patients underwent a thyroidectomy procedure at Aintree University Hospitals NHS Foundation Trust (AUH) between January 2007 and May 2012. Of these, 34 cases were documented as having a RSG. Review of each patient's preoperative computerized tomography imaging identified 19 patients with massive RSG. There was one case of failed intubation. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed through the neck with no requirement to proceed to sternotomy. There were no instances of postoperative respiratory problems or tracheomalacia. Three patients suffered recurrent laryngeal nerve (RLN) injuries.

When managed within a dedicated H&N operating theatre we have found a low incidence of difficult tracheal intubation, difficult mechanical ventilation nor postoperative respiratory difficulties in patients with massive RSG and mid-tracheal compression because of benign multi-nodular goitre. Surgical complications, however, are more frequent than those associated with cervical thyroidectomy with RLN injury and postoperative bleeding more likely.