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ENDORAMAConference
Ben James2/20/14
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HPI
57 year old female
2007 thyroid nodule palpated by PCP
Diagnosed with multinodular goiter
High T3 (212), low TSH (<0.01), elevated anti-TPO antibodies
RAI scan in 2009 Increased uptake in left known nodule, no cold nodules
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HPI
Noted increase in size of left nodule
Daughter came home from college and noticed her mother sounded stridorous
No shortness of breath, difficulty swallowing, or voice changes
Forced her mother to see her endocrinologist
TSH <0.01
T3 434
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PMHxPMH:
HyperthyroidismMultinodular goiter
PSH: AbdominoplastyLap bandBilateral knee replacements
Social:TeacherNo history of radiation
Family:Noncontributory
Meds: methimazole, MVM
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Imaging
Ultrasound:Enlarged thyroid with multiple nodules bilaterally Left lobe increasing in size, now 9cm and composed of conglomerate nodules which have grown together
Radio-active iodine scan:Dominant nodule in left lobe now a cold noduleToxic multinodular goiter otherwise
FNA of large left nodule:Papillary thyroid cancer
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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CT
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ENT visit
Flexible larygoscopyBilateral vocal cord paresis
Arrangements made for OR to have cardiac surgery available for ECMO if unable to intubate
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OR
Bilateral femoral vein lines placed
Awake fiberoptic intubation with ENT and cardiac surgery on standby
Total thyroidectomyStrap muscles adherent to thyroidLeft jugular compressed and adherent to thyroid mass
Left levels 2 and 3 lymph nodes enlarged on imaging but normal appearing in OR
Resected, no formal neck dissection
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OR
Bilateral recurrent laryngeal nerves visualized intact
Nerve stimulatorRight nerve conducted a signalLeft nerve did not conduct a signal
Mild tracheomalaciaTracheopexy per ENT
Drain placed
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Immediately postop
Good respiratory dynamics, received dexamethasone during casePatient extubated easily in ORPreoperative stridor noted to be worse, but breathing and saturating wellStridor continued
Despite racemic epi and duonebsSaturations dropped to 88-92%
Attempt at facemask; ABG sent showing good oxygenation but pCO2 of ~65BiPAP used, pCO2 dropped appropriately
90min postoperatively, patient saturating well but expressing that she is feeling very tired, having difficulty breathing
Elective reintubationVocal cord edema encountered
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Hospital stay
ICU for 36 hours intubated and sedated
Dexamethasone for first 24 hours
Good cuff leakExtubated easily, weaned to room air quickly
Stridor had resolvedHoarse voice
Discharged home PostOp day 5
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