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 3rd and 4thtracheal 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.