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\begin{document}

\title{Tracheal Necrosis Following Two-Stage Thyroidectomy}



\author[1]{Taylor Colvin}%
\author[1]{Chris Selinsky}%
\affil[1]{OhioHealth}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\begin{abstract}
Following surgery for thyroid carcinoma, tracheal necrosis is extremely
rare with few reports in literature. We report a patient who underwent a
thyroid lobectomy for potential papillary carcinoma, followed by a
completion thyroidectomy due to follicular variant papillary carcinoma
pathology. Management was successful after debridement and tracheostomy,
followed by decannulation.%
\end{abstract}%



\sloppy


\textbf{Abstract}

Tracheal necrosis is a rare complication of a thyroidectomy, almost
exclusively following resection of invasive thyroid carcinoma with
tracheal involvement. We report a case of delayed tracheal necrosis
following a routine thyroidectomy for non-invasive papillary thyroid
carcinoma likely secondary to a postoperative seroma. This complication
was successfully managed with a temporary tracheostomy.

\textbf{1 INDRODUCTION}

When preparing a patient for a thyroidectomy, the more common
complications are discussed with them prior to surgery which may include
recurrent nerve injury, temporary or permanent damage to parathyroid
glands, need for additional surgeries, etc. Following surgery for
non-invasive thyroid carcinoma, tracheal necrosis is extremely rare with
very few reports in literature. We report successful management of
tracheal necrosis in a patient who underwent a thyroid lobectomy for
potential papillary carcinoma, followed by a completion thyroidectomy as
tissue examination revealed a 3.1cm follicular variant papillary
carcinoma.

\textbf{2 CASE PRESENTATION}

A 31-year-old female with past medical history of anxiety presented with
a thyroid nodule that was palpated during an annual check up with her
PCP. At the time of presentation, she was asymptomatic and denying
symptoms of dysphagia, hoarseness of voice, and odynophagia. She does
report a family history of thyroid carcinoma in her mother at 60 years
old that was treated with thyroidectomy and radioactive iodine.
Ultrasound and FNA were performed revealing a TR3 follicular neoplasm
measuring 3.7 x 1.9 x 3.5 cm and pathology suspicious for follicular
neoplasm. Pathology was then sent for AFIRMA molecular testing with
``suspicious for malignancy'' results indicating a 50\% risk of
malignancy. Patient was presented with options of a total thyroidectomy
or a hemithyroidectomy, with patient electing the latter.

The right hemithyroidectomy was performed utilizing bipolar cautery and
a harmonic scalpel for hemostasis. There was no sign of adjacent tissue
invasion of the tumor, minimal amount of bleeding was encountered during
the procedure, and the only anatomical variant noted was the absence of
a thyroid isthmus. Final pathology revealed follicular variant papillary
carcinoma with tumor measuring 3.1 cm with tumor capsule invasion, which
was subsequently staged as pT2, pNx (stage 1). Seven days after the
right hemithyroidectomy, patient underwent a completion thyroidectomy
due to pathology results. Procedure again was uneventful with minimal
bleeding (approximate EBL 20cc), followed by removal of any residual
thyroid tissue on the right side.

Immediate post-operative course was uncomplicated apart from a low PTH
treated with temporary oral calcium and vitamin D supplementation. She
was seen postoperatively in the clinic 3 days following completion
thyroidectomy when mild drainage from incision site was noted along with
peri-incisional erythema. Needle aspiration was performed removing 14cc
of serosanguineous fluid with patient expressing relief of pressure. She
was prophylactically placed on cephalexin 500mg 3 times per day. Five
days later (8 days since completion thyroidectomy) she presented to our
clinic with an open wound with air escape noted.

Patient was taken to the operating room for wound exploration. The wound
was irrigated with saline when breakdown of tissue noted and debrided
between cartilaginous rings 2, 3, and 4 with the largest amount of
breakdown between 3 and 4 as seen in Figure 1. A \#6 Shiley tracheostomy
tube was placed between 3\textsuperscript{rd} and
4\textsuperscript{th}tracheal rings, with 4-0 Ethilon suture placed on
either side of wound. Patient was then admitted to the hospital for
observation and discharged on post-operative day 3. One week following
discharge she was seen in clinic for follow up, her tracheostomy tube
was downsized to a \#4 Shiley tracheostomy tube. Using a Passy Muir
Valve patient was able to phonate well with a mild amount of air escape
in her neck.

2 weeks later, approximately 1 month since the completion thyroidectomy
she was taken to the OR for direct laryngoscopy with rigid bronchoscopy.
Findings revealed mild subglottic stenosis with no signs of tracheal
necrosis and was subsequently decannulated. Over the following 2-3
months the stoma closed appropriately with no further signs of a
tracheocutaneous fistula or symptoms of dysphagia, dysphonia, or
stridor. She did have I-131 radioactive ablation without issue.

\textbf{3 DISCUSSION}

The formation of a tracheocutaneous fistula following a thyroidectomy
may be secondary to several etiologies. It has been previously reported
following radiation therapy\textsuperscript{2}, iatrogenic tracheal
injury, prolonged intubation following procedure, infection of surgical
site, excessive cautery on tracheal wall\textsuperscript{4}, or pressure
induced ischemia\textsuperscript{3}. Many surgeons attempt to minimize
excessive cautery around the trachea to prevent necrosis, using cautery
on a lower setting when necessary\textsuperscript{4}. Some authors
report tracheomalacia as a potential cause of tracheal necrosis as
thyroid tissue may act as framework for the trachea, causing tracheal
collapse when removed.\textsuperscript{1}

In our case we postulate the formation of a seroma postoperatively
potentially led to a pressure induced necrosis of the anterior tracheal
wall. Only one case has been reported to our knowledge of tracheal
necrosis in the setting of a post-operative seroma. The pathogenesis of
a seroma induced pressure necrosis is likely similar to the hypothesized
manner in which elevated cuff pressure leads to tracheal necrosis. The
hypothesis is the cuff pressure exceeds perfusion pressure of tracheal
mucosa, resulting in pressure necrosis.\textsuperscript{5} The other
manner in which tracheal necrosis may have occurred is due to disrupting
the blood supply to the tracheal wall. Blood supplying the trachea stems
from the inferior thyroid artery. These branches can be very delicate
and easily interrupted with cauterization during removal of thyroid
tissue.\textsuperscript{5} The largest risk factor in this patient for
tracheal necrosis would be the need for a second procedure for complete
removal of thyroid tissue. Compared to a single procedure, a two-step
procedure would increase the amount of time intubated and lead to repeat
use of cautery around anterior tracheal wall. Other common risk factors
for tracheal necrosis that were not a factor in our patient include
post-operative infection, large thyroid goiter that might have
compromised tracheal blood supply, marked bleeding during procedure
leading to excessive cauterization for hemostasis, prior chemoradiation,
among others.\textsuperscript{7}

\textbf{4 Conclusion}

In retrospect, a single stage procedure as well as a more aggressive
post-operative follow up course may have prevented this complication.
Risks of performing a hemithyroidectomy in place of a complete
thyroidectomy during initial procedure were discussed with patient who
elected to assume these risks. However, the need for a second procedure
may have led to the formation of tracheal necrosis. Patient reported
noticing seepage from her incision for 1-2 days prior to follow up
appointment wherein she had 14cc of fluid aspirated from the seroma, had
she followed up sooner there may have been less pressure induced
compromised blood supply to the tracheal wall.

\textbf{ACKNOWLEDGEMENTS}

None

\textbf{CONFLICT OF INTEREST}

None declared

\textbf{AUTHOR CONTRIBUTIONS}

TC and CS were involved in reviewing the literature and preparing and
editing the manuscript, and authors approved the final version of the
manuscript.

\textbf{ETHICAL APPROVAL}

This study does not require any ethical committee approval

\textbf{CONSENT}

Written consent was obtained from the patient to publish this report in
accordance with the journal's patient consent policy

References

1: Shiao JC, Lee KW, Kuo WR, Chiang FY, Ho KY, Wang LF. Persistent large
subcutaneous emphysema after thyroidectomy. Otolaryngol Head Neck Surg
2006;135:814-5.

2: Takiguchi Y, Okamura HO, Kitamura K, Kishimoto S. Late
laryngo-tracheal cartilage necrosis with external fistula 44 years after
radiotherapy. J Laryngol Otol 2003;117:658-9.

3: Weaver K, Folch E, Dent L, Flenaugh EL. Cuff pressure tracheal
necrosis. J Bronchol 2006;13:212-3

4: Cord\selectlanguage{greek}σ\selectlanguage{english}n C, Fajardo R, Ram\selectlanguage{greek}ν\selectlanguage{english}rez J, Herrera MF. A randomized,
prospective, parallel group study comparing the Harmonic Scalpel to
electrocautery in thyroidectomy. Surgery 2005;137:337-41.

5: Grilo H. Surgery of the trachea. Curr Probl Surg 1970:3-59.

6: Golger A, Rice LL, Jackson BS, Young JE. Tracheal necrosis after
thyroidectomy. Can J Surg. 2002;45:463--464.

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