Post on 04-Sep-2019
transcript
Patient had presented to the OPD with complaints of
hoarse voice since three yrs, snoring since two months
and difficulty breathing since two weeks, increasing on
exertion.
Patient was a case of papillary ca thyroid , underwent
total thyroidectomy and central compartment
dissection. she developed post op left vocal cord palsy
with hoarseness of voice.
She was sent for radio active iodine therapy and was on
regular follow up for 6 months ,she was on Tab
Thyroxine 150micro gm.
Patient had complaints of snoring since two months,
which was insidious in onset, gradually worsening,
aggravated with URTI.
Patient developed difficulty breathing two weeks ago
after strenuous work( lifting of heavy weights), which
was insidious in onset, spontaneous, aggravating on
exertion.
No history of cough during swallowing liquids or
solids.( aspiration)
No history of difficulty in swallowing , referred pain
to ear, decreased hearing or aural fullness.
No history of nasal obstruction, bleeding from nose,
headache.
Past history:
Not a known case of hypertension, diabetes, bronchial
asthma, epilepsy, TB, CAD.
Personal history:
Consumes mixed diet, bowel and bladder habits are
regular, sleep – disturbed for last 2 months and appetite
adequate. Habits-no addictions.
Menstrual history : regular
Family history: Not significant
Drug history: No known drug allergies.
Patient was conscious, coherent and cooperative , moderately built & nourished .
Stridor + - biphasic Pulse rate - 122/min BP – 112/76 mm of Hg RR: 32/min Accessory muscles of respiration - active No Pallor/cyanosis / sweating No Icterus, no Clubbing, no koilonychia, no Pedal edema,
no Generalized Lymphadenopathy
Systemic examination:
Respiratory system - B/L air entry.
Normal vesicular breath sounds.
Cardiovascular system- normal.
Per abdomen- normal.
Oral cavity examination: No trismus Lips: normal Gums: normal Teeth: normal Anterior 2/3rd of tongue: normal Floor of mouth : normal Hard palate: normal Buccal mucosa: normal Gingivolabial, gingivolingual, gingivobuccal sulci:
normal Retromolar trigone: normal
Orophayrnx:
Uvula & Soft palate :Normal
Anterior pillars: Normal
Tonsils : normal
Posterior pillars: Normal
Posterior pharyngeal wall: Normal
Visible part of posterior 1/3 of tongue: Normal
Indirect laryngoscopy: Base of tongue Vallecula Epiglottis normal Aryepiglottic folds B/L Pyriform sinuses: normal B/L False cords: oedematous B/L True cords: oedematous, immobile, in paramedian
position. Supraglottis and visible subglottis did not reveal any
growth and was normal.
A Scar of thyroidectomy seen- healthy
No palpable neck nodes in level I-VI
laryngeal crepitus present.
No other masses palpable in the neck.
Nose: External framework: normal Columella: normal Vestibule : normal Anterior Rhinoscopy: Deviated nasal septum to left Turbinates: bilateral inferior turbinate
hypertrophy Roof : normal Floor : normal Mucosa: normal
Right ear Pinna:Normal Preauricular area:
Normal Post auricular area:
Normal External auditory
canal: clear Tympanic membrane:
intact. TFT –B/L:normal
heearing
Left ear Pinna:Normal Preauricular area:
Normal Post auricular area:
Normal External auditory
canal: clear Tympanic membrane:
intact.
Clinical diagnosis
“Bilateral vocal cord palsy”
Differential diagnosis 1. Recurrent ca thyroid. 2. Fibrosis 3. Glomus vagale 4. Idiopathic.
Plan 1. To relieve stridor with emergency
tracheostomy.
2. To Investigate the cause.
3. lateralization of vocal cord if no cause detected.
Complete Blood Picture : Hb% :- 13.4 gm% TLC :- 9100 cu.mm Neutrophils :- 64% Lymphocytes :- 30% Eosinophils :- 04% Monocytes :- 02% Basophils :- 0% Platelet count :- 3.60 lakhs /cu mm Smear :- Normocytic /Normochromic
Blood group :- O Rh typing :- POSITIVE Bleeding time : 2 mins 00sec Clotting time :4 mins 00sec Serum electrolytes: Sodium :- 135mmol/L Potasium:- 3.3mmol/L Chloride:- 99 mmol/L RBS :- 110mg/dl Serum Creatinine :- 1.01mg /dl Urea : 17mg/dl APTT: 28sec; PT: 14sec, INR: 1
Complete Urine Examination: Normal
SEROLOGY:
HBsAg:- Non reactive
HIV :- Non Reactive
ECG :- Normal
Chest X Ray :- normal.
USG neck- thyroid absent, no lymph nodes in central
compartment and lateral neck. No other masses seen.
Position : patient was placed in supine position with
extension of neck
Under aseptic condition, part painted and draped.
Incision : a horizontal incision given in the central
neck through the old thyroidectomy incision.
Midline dissection done and 2nd tracheal ring
identified.
Stoma created at 2nd tracheal ring.
A cuffed portex tracheostomy tube no.7 inserted ,
patency confirmed and tube secured.
Post operative period was uneventful, daily
tracheostomy tube care and dressings were done.
Patient was stabilised, no tachypnoea, no snoring in
post operative period.
Tracheostomy tube changed on POD 3
Options for further treatment:
1. Endoscopic laser unilateral cordectomy.
2. Laryngofissure with unilateral cordectomy.
Plan : Laryngofissure with left posterior Cordectomy under
general anaesthesia
Flexometallic tube passed through tracheostomy stoma and
tube fixed on to the chest.
Position : patient placed in supine position with neck
extension
Incision : a horizontal incision given at level of cricothyroid
membrane over the skin crease
Subplatysmal flaps raised superiorly up to hyoid, inferiorly just above tracheostoma.
Strap muscles divided in the midline.
Cricothyroid membrane is split , anterior commissure identified from below.
Perichondrium over thyroid cartilage is elevated, thyroid cartilage identified and incised inside out.
Thyroid lamina retracted. vocal cords and ventricles visualised
The left vocal cord
separated from vocal
process and posterior
part of vocal cord
excised using bipolar
cautery.
Thyroid lamina and perichondrium closed.
Cricothyroid membrane repaired.
Incision was closed in layers with 3.0 vicryl.
Drain placed and patient shifted to post op with tracheostomy tube
NBM for 6 hours. I/V/F: DNS and RL at 100ml/hr Inj TAXIM 1gm IV BD Inj VOVERAN 75mg IM BD Inj RANTAC 50mg IV BD Inj HYDROCORTISONE 100mg IV 6th hourly Tab CHYMEROL FORTE TID Tracheostomy tube care
Patient was allowed to take soft diet. VITALS: BP: 110/70mm of Hg PR: 88 bpm SpO2 maintained at 98% with tracheostomy
tube on room air On L/E of neck: surgical emphysema present
over anterior part of neck Drain collection was 5ml
Inj TAXIM 1gm IV BD
Inj VOVERAN 75mg IM BD
Inj RANTAC 50mg IV BD
Tab CHYMEROL FORTE TID
Tab ELTROXIN 150 micro gm
Tab SHELCAL 500mg OD
Tracheostomy tube care
VITALS: BP: 130/70mm of Hg PR: 88 bpm SpO2 maintained at 98% with tracheostomy
tube on room air On L/E of neck: surgical emphysema reduced
over anterior part of neck Drain collection : 2 ml
POD 5: Drain removed, neck wound healthy, surgical emphysema subsided.
POD 7 : Sutures removed ad neck wound healed.
Same treatment was continued till POD 10
POD 14: portex cuffed tracheostomy tube changed and replaced with Jackson’s metallic tracheostomy tube, no.32
POD 15: patient was discharged on metallic tracheostomy tube after explaining, training and counselling regarding tube care and advised to continue Tab ELTROXIN 150 micro gm OD, Tab SHELCAL 500mg OD
POD 15: patient was discharged on metallic tracheostomy tube after explaining, training and counselling regarding tube care and advised to continue Tab ELTROXIN 150 micro gm OD, Tab SHELCAL 500mg OD
Patient was asked to review after two weeks Patient reviewed on 10.03.2017 for
decannulation and observation, when she was admitted, conservatively managed.
Stoma was closed and patient kept under observation, no signs of respiratory distress were seen.
Patient was sent home on 14.03.2017 Discharge status: no stridor or respiratory
distress