Dr. Aruna kommineni 3rd year PG

Dept. Of E.N.T.

Name : XXX

Age: 35 yrs

Sex : female

Occupation : Agricultural labour

Date of admission: 03/02/2017

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

Thank you