Dr. Aruna kommineni 3 rd year PG Dept. Of E.N.T.

Transcription

1 Dr. Aruna kommineni 3 rd year PG Dept. Of E.N.T.

2 Name : XXX Age: 35 yrs Sex : female Occupation : Agricultural labour Date of admission: 03/02/2017

3 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.

4 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.

5 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)

6 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.

7 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.

8 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

9 Systemic examination: Respiratory system - B/L air entry. Normal vesicular breath sounds. Cardiovascular system- normal. Per abdomen- normal.

10 Oral cavity examination: No trismus Lips: normal Gums: normal Teeth: normal Anterior 2/3 rd of tongue: normal Floor of mouth : normal Hard palate: normal Buccal mucosa: normal Gingivolabial, gingivolingual, gingivobuccal sulci: normal Retromolar trigone: normal

11 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

12 Indirect laryngoscopy: Base of tongue Vallecula Epiglottis Aryepiglottic folds B/L Pyriform sinuses: normal B/L False cords: oedematous normal B/L True cords: oedematous, immobile, in paramedian position. Supraglottis and visible subglottis did not reveal any growth and was normal.

13 A Scar of thyroidectomy seen- healthy No palpable neck nodes in level I-VI laryngeal crepitus present. No other masses palpable in the neck.

14 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

15 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.

16 Clinical diagnosis Bilateral vocal cord palsy Differential diagnosis 1. Recurrent ca thyroid. 2. Fibrosis 3. Glomus vagale 4. Idiopathic.

17 Plan 1. To relieve stridor with emergency tracheostomy. 2. To Investigate the cause. 3. lateralization of vocal cord if no cause detected.

18 Complete Blood Picture : Hb% : gm% TLC : cu.mm Neutrophils :- 64% Lymphocytes :- 30% Eosinophils :- 04% Monocytes :- 02% Basophils :- 0% Platelet count : lakhs /cu mm Smear :- Normocytic /Normochromic

19 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

20 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.

21 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 2 nd tracheal ring identified.

22 Stoma created at 2 nd 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

23 Options for further treatment: 1. Endoscopic laser unilateral cordectomy. 2. Laryngofissure with unilateral cordectomy.

24 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

25 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

26 The left vocal cord separated from vocal process and posterior part of vocal cord excised using bipolar cautery.

27 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

28 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 6 th hourly Tab CHYMEROL FORTE TID Tracheostomy tube care

29 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

30 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

31 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

32 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

33 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

34 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

35 Patient was asked to review after two weeks Patient reviewed on 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 Discharge status: no stridor or respiratory distress

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37 Thank you