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Upper airway compromise secondary to edema in Graves’ disease

[Atteinte des voies aériennes supérieures secondaire à un dème dans la maladie de Graves]

William Li Pi Shan, MD FRCPC^*, Roupen Hatzakorzian, MD FRCPC^*, Mark Sherman, MDCM FRCPC MACP and Steven B. Backman, MDCM PHD FRCPC^*

^* From the Department of Anesthesia, and the
Department of Endocrinology, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada.

Address correspondence to: Dr. William Li Pi Shan, Department of Anesthesia, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, Quebec H3A 1A1, Canada. Phone: 514-934-1934 ext. 34880; Fax: 514-843-1723; E-mail: william.li_pi_shan{at}mail.mcgill.ca

Purpose: We report an unusual case of upper airway compromise in a patient with Graves’ disease. We speculate that this complication may be due, in part, to poorly controlled hyperthyroidism.

Clinical features: A 26-yr-old female suffering from Graves’ disease underwent a total thyroidectomy. Awake fibreoptic intubation was attempted because of a large goiter and orthopnea. Upper airway edema impeded the passage of an armored 7.5 mm endotracheal tube. She was subsequently intubated awake with a regular 7.5 mm endotracheal tube under direct laryngoscopy over an Eschmann bougie. The patient was extubated in the operating room over a tube exchanger. Two hours later she developed stridor and upper airway obstruction. Using direct laryngoscopy, she was reintubated with difficulty because of upper airway edema. At this time, she manifested signs of thyrotoxicosis which were managed medically. On postoperative day three she underwent a tracheostomy after failing a trial of extubation. The upper airway was edematous with minimal vocal cord movement. On postoperative day nine the tracheostomy was downsized and the patient was sent home. The vocal cords were still edematous with minimal movement. Three weeks later, she demonstrated normal right vocal cord movement and weak left vocal cord movement, and the tracheostomy was decannulated.

Conclusions: Uncontrolled hyperthyroid patients with large goiters secondary to Graves’ disease may develop edema of the upper airway. A high degree of vigilance for airway obstruction is necessary, with a carefully planned approach at each stage of the patient’s hospital course to treat this potentially life-threatening situation.