Stridor on day 6 after total thyroidectomy
A 55-year-old woman is day 6 after total thyroidectomy for a 4 cm multinodular goitre. The operation note records that both recurrent laryngeal nerves were identified and preserved, and that she was extubated at the end of the case. She now has inspiratory stridor at rest, a breathy voice, and can only speak in three- to four-word phrases. She has no aspiration, no neck haematoma, and the wound is soft. Respiratory rate is 26/min, SpO2 is 93% on room air and she is using accessory muscles. Flexible nasendoscopy shows both vocal folds in a paramedian position, immobile on both phonation and respiration, with a glottic gap of about 2 mm; there is no supraglottic oedema and no pooling of secretions. Corrected calcium is 2.18 mmol/L. She is frightened and asks whether she will need 'a hole in her throat'.
1. Set out your airway management for the next hour, with the reasoning behind each step and the alternatives you would consider.
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Assessment. This is impending upper airway obstruction from bilateral vocal fold immobility, not stridor to be observed. She has objective signs of respiratory distress at rest (tachypnoea, accessory muscle use, desaturation) with a 2 mm glottic gap - a small further reduction in airway calibre or fatigue will tip her into complete obstruction.
Immediate actions. Sit her upright, high-flow oxygen with continuous oximetry and capnography, IV access, and no sedatives or opioids. Call for senior anaesthetic and ENT support immediately and move her to a monitored area with difficult-airway equipment, a range of small tubes, a rigid bronchoscope and surgical airway set available. Exclude a haematoma (the wound is soft here) and hypocalcaemia (normal, but check magnesium). Re-examine the larynx with a second senior clinician to confirm the finding. Give nebulised adrenaline only as a temporising measure, not as treatment.
Securing the airway. If she remains stable with a 2 mm gap, a planned controlled intubation or a semi-elective tracheostomy in theatre within the next hour or two is far safer than a crash induction. I would favour awake tracheostomy under local anaesthetic if the airway is marginal and the anatomy allows, since it avoids the risk of a 'cannot intubate, cannot ventilate' scenario from attempting to pass a tube through an immobile, narrow glottis. If intubation is chosen, use a smaller tube (5.0–5.5) with the most experienced operator, video laryngoscopy, and a pre-declared plan for front-of-neck access. Do not paralyse before the airway plan is agreed. The tracheostomy also protects against aspiration and allows her to be weaned from a speaking valve later.
2. Assuming the nerves were genuinely preserved and she has a temporary tracheostomy, how do you plan for recovery versus definitive glottic surgery, and what determines decannulation?
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Natural history. When both recurrent laryngeal nerves were identified and preserved, a substantial proportion of bilateral immobility after thyroidectomy recovers, typically within 6–12 months; permanent bilateral palsy occurs in well under 1% of thyroidectomies. Plan positively, but with a defined endpoint.
Recovery pathway. Voice therapy from week 1 to optimise breath support and reduce compensatory strain. Flexible laryngoscopy monthly for the first 3 months, then at 6 months. Laryngeal electromyography at 3–6 months, which adds prognostic information: absent voluntary motor unit potentials and fibrillations at that stage make recovery less likely, while nascent units suggest it is ongoing. Check thyroid function, calcium and vitamin D, and treat hypothyroidism or hypocalcaemia if present, since both worsen neuromuscular recovery. Document serial findings and share them with the patient.
Definitive glottic enlargement. If there is no functional recovery by 6–12 months, or if the tracheostomy cannot be weaned by about 6 months, offer a static procedure: endoscopic carbon dioxide laser posterior transverse cordotomy, or suture lateralisation of one vocal fold (preferred where the fold is not fixed in the midline or where a reversible option is desired), or partial arytenoidectomy. All trade airway for voice; discuss that voice may become weaker and aspiration risk may rise. If nerve function does return, the same procedures become unnecessary.
Decannulation. Criteria: stable or improving glottic aperture, ability to tolerate tracheostomy capping for 24–48 hours with no distress and acceptable saturations and blood gases, effective cough, minimal aspiration on assessment, and manageable secretions. Do the trial with continuous observation and a clear plan to reinsert if needed.
3. How would you discuss this complication with her and her family, and what would you document?
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The conversation. Be direct, take responsibility and avoid euphemism. Explain that both vocal folds are not moving, that this is a recognised complication of thyroid surgery occurring in roughly 1 in 100–200 total thyroidectomies, and that because both nerves were seen and preserved there is a good chance of recovery over months rather than days. Explain why the tracheostomy is being done (her airway is too narrow) and that it is temporary in most cases, that she will be able to speak with a valve, and what the milestones are. State plainly that if the nerves do not recover, a small operation on the vocal fold can usually allow the tube to be removed, at some cost to voice quality. Check she has understood, allow questions, and involve her next of kin with her consent.
Who should speak to her. Ideally the operating surgeon, with the on-call team present, and in line with the local duty-of-candour process - a complication of treatment should be disclosed openly and promptly, not left to a junior to explain.
Documentation. The finding and timing; the laryngoscopy and who performed it; the airway observations; the clinical reasoning and the alternatives considered; the discussion with anaesthesia and who was called; exactly what was said to the patient and family, in plain terms; the consent discussion for tracheostomy including the risks of bleeding, infection, scarring, tracheal stenosis, and the possibility of a permanent stoma; and the follow-up plan with named dates. Record her questions and concerns, particularly her fear of a permanent 'hole in the throat', and note that she asked it. Add an entry to the incident-reporting system and arrange review of the operative and anaesthetic records.