Post-thyroidectomy tracheomalacia: minimal risk despite significant tracheal compression.

Background: Tracheomalacia is a feared complication of goitre surgery, but considered rare in the Western World. This study aimed to estimate the risk of tracheomalacia in a contemporary series of patients with goitres causing significant tracheal compression.
Methods: A retrospective review was conducted of thyroidectomies performed in a UK tertiary referral centre over a 30 month period. Anaesthetic, operative, radiological, and pathological data were obtained from medical notes and hospital software systems.
Results: Of 334 patients who underwent thyroid surgery, preoperative CT scan was performed in 101 (30%). Tracheal compression was reported in 62 patients (19%) with minimum tracheal diameter ranging from 2 to 15 mm (mean 7.6 mm) due to multinodular goitre (n=50), malignancy (n=10), or thyroiditis (n=2). Critical compression <5 mm was observed in 18 patients (6%) and 35 patients had compression to 6-10 mm. Awake fibreoptic intubation was performed in eight patients (six of those with tracheas <5 mm) and asleep fibreoptic intubation was performed in one. Standard intubation was performed otherwise. All patients were recovered on a general surgical ward. None required tracheostomy or tracheal stenting. The incidence of tracheomalacia was 0 (95% confidence interval 0.0-4.8%). Mean length of stay was 2.4 days in those with tracheas <5 mm and 2.0 days in those >5 mm.
Conclusions: We found no evidence of tracheomalacia in high-risk patients with significant tracheal compression. This supports prior work on retrosternal goitres suggesting that the risk of tracheomalacia is minimal in modern thyroid surgery. For risk management, however, we would still advocate that such patients be managed in units with multispeciality support.