CASE PRESENTATIONS
Case 1 Suspected Malignancy in Retropharyngeal Nodes
An asymptomatic 37-year old woman with a history of papillary cancer of
the thyroid, presented in December 2019, referred for suspected
malignancy involving high retropharyngeal lymph nodes bilaterally,
detected on a contrasted Computed Tomography (CT) in October 2019
(figure 2).
The patient had four previous surgeries for well-differentiated
papillary thyroid cancer at other institutions. In 2006 she underwent
total thyroidectomy, removal of one central compartment node, and 9
lateral neck lymph nodes of which 6 contained malignancy. Based on
abnormal ultrasounds and thyroglobulin levels over the years, the
patient was taken back to surgery on three subsequent occasions,
including a comprehensive procedure in 2018, with revision neck
dissection bilaterally including level 6 and left level 5. Seven of 31
lymph nodes were positive.
Her only medication was oral levothyroxine. Head and neck physical
examination was notable only for surgical scars.
Due to the unusual location of these lymph nodes, there was concern that
these might represent a more aggressive lesion. The CT was indistinct in
evaluating the borders of the lesions. There were additional involved
lymph nodes more inferiorly in the right neck and some questionable
lymph nodes by CT criteria on the left. Review of her surgical pathology
from 2018 confirmed classical papillary thyroid cancer. Her
Thyroglobulin was 6.0 unstimulated. Stimulated Thyroglobulin elevated to
29.3.
We advised contrasted magnetic resonance imaging (MRI), and Positron
Emission Tomography/ Computed Tomography (PET-CT) to further evaluate,
along with presentation at our multidisciplinary head and neck tumor
conference. The MRI showed the well-encapsulated cystic retropharyngeal
lymph nodes more distinctly (figure 3), with 2 cm as the largest
dimension. The PET-CT was negative for Fluorodeoxyglucose uptake,
suggesting low-grade lesions. The retropharyngeal lesions were felt to
be inaccessible for fine needle aspiration.
We recommended bilateral revision neck dissection followed by bilateral
exploration of the parapharyngeal space, carefully following the carotid
upwards to excise the retropharyngeal lymph nodes. Laryngeal nerve
integrity monitoring would be used. Mobilization of the tail of parotid,
ligation of the external carotid artery, and possible identification of
the facial nerve in the parotid were felt to be potentially necessary to
achieve the exposure of the retropharyngeal nodes. The patient was
consented appropriately regarding risks, including cranial neuropathies
and first bite syndrome.
The patient obtained second opinion and presented again in early March,
and surgery was scheduled two weeks later. By March 15 the COVID-19
pandemic was in ascendance and elective surgery was suspended. The
working rule in our Case Review Committee had been to delay surgery for
well-differentiated thyroid cancer. This case was pre-reviewed by
committee members because of the unusual anatomic location of the
lesions. The recommendation was to repeat the MRI to confirm stability
on two similar studies. Repeat MRI confirmed no changes in the lesions
between January and April. Based on this, we recommended not to
hospitalize during the pandemic and planned surgery in three months.
CASE 2 Massive Goiter with Severe Tracheal Compression
A 62-year old woman presented to our county hospital emergency
department reporting dyspnea on exertion.
She now was noted to have reduced oxygen saturation after exertion. CT
with iodinated contrast at our facility confirmed severe tracheal
compression and a 5 mm tracheal width (figure 4). The compression was
positional and on certain axial images the tracheal lumen appeared
completely obscured (figure 5). The patient received intravenous
dexamethasone during this admission, respiration improved, and she was
discharged and counseled to avoid heavy exertion and avoid laying on the
right side.
The patient also had several elevated calcium levels and parathyroid
hormone levels (PTH), with her highest preoperative PTH at 110 pg/ml and
calcium at 11.4 mg/dl. Subsequent ultrasound and ”Four Dimensional” CT
(Respiration correlated /parathyroid protocol CT) did not localize a
parathyroid adenoma.
The next week the patient was back in the emergency room with dyspnea.
Due to breathing difficulties we cancelled a planned parathyroid
(technetium 99 sestamibi) nuclear scan, and surgery was scheduled
urgently. The plan for airway management was awake fiberoptic intubation
with the smallest reinforced endotracheal tube that would fit over a
flexible bronchoscope and was long enough to reach beyond the narrowing
of the trachea, which was estimated to be a size six tube. We would not
be able to use the larger diameter tubes with electrodes for nerve
integrity monitoring. The emergency backup plan for airway management
was a cricothyroidotomy to allow placement of a smaller diameter,
shorter, pediatric size tube. At this point the pandemic was in its
ascendance. Significant questions were raised regarding the risk of
infection of the team during emergency airway management. Therefore,
given that she was comfortable on room air at rest, the patient was
discharged, and surgery was delayed for a few days so that it could be
moved to a cardiac bypass operating room which was set up for
extracorporeal membrane oxygenation (ECMO). She also was tested and
negative for COVID-19 by nasopharyngeal swab polymerase chain reaction
(RT-PCR) assay.
At surgery all staff in the room wore N95 masks and full PPE, including
face shields, hats and gowns. Under local anesthetic, the patient
underwent bilateral femoral line placement to allow for more rapid
conversion to ECMO if necessary. The nose and throat were topically
anesthetized with sparing use of topical lidocaine cream, avoiding
aerosolized topical anesthetic. She was successfully intubated awake
using a fiberoptic bronchoscope and size 6 reinforced tube, which just
reached the distal obstruction. The plan had been to initiate ECMO if
fiberoptic intubation failed, in order to reduce risk of aerosolization
of viral particles during an awake cricothyroidotomy.
The multinodular goiter was excised with visualization and preservation
of the recurrent laryngeal nerve. The goiter was bluntly delivered from
the mediastinum. Two obviously enlarged parathyroids were encountered,
and frozen section biopsy suggested parathyroid hyperplasia. We removed
both ipsilateral parathyroids and the intraoperative PTH dropped to 48.
Representative frozen section biopsy confirmed benign colloid nodule. At
this point, we elected not to explore contralaterally.
The patient recovered uneventfully with no respiratory issues and was
discharged 24 hours after surgery. Final pathology confirmed the
intraoperative diagnoses.
CASE #3 Advanced Oral Cavity Cancer With False Positive COVID-19 RT-PCR
A 60-year old man presented with a 7-month history of a right sided oral
lesion, progressive over time and increasingly painful.
A biopsy showed invasive moderately differentiated squamous cell
carcinoma. Past medical history included myocardial infarction and
angioplasty 3 years before. His only medication was aspirin. Patient had
smoked cigarettes for twenty-five years, used chewing tobacco, and drank
4 drinks of liquor daily.
Physical examination revealed a right posterior buccal lesion, bulging
into the cheek and extending from inferior alveolar ridge to superior
alveolar ridge with trismus.
CT with iodine-based contrast media and PET-CT demonstrated the oral
lesion with limited bone erosion at the superior alveolar ridge. A
one-centimeter round level 1B node was positive on PET-CT.
The patient was scheduled for tracheostomy, full-thickness buccal
resection, marginal mandibulectomy, partial maxillectomy, right neck
dissection, and anterolateral thigh free flap reconstruction. Committee
review classified surgery as urgent and without equivalent non-surgical
alternatives. He had one negative COVID-19 RT-PCR performed three days
before surgery.
Shortly before surgery our policy changed to require that all urgent
mucosal surgeries have two COVID-19 RT-PCR tests. Since testing had a
3-day turnaround time, a second test was sent on the morning of surgery,
but surgery proceeded. The operation was uncomplicated. Staff wore N95
masks, face shields, and gowns. His postoperative course was typical,
but on postoperative day 3 his preop COVID-19 RT-PCR test resulted
positive and the patient was moved to a COVID-19 ward. The patient never
had symptoms.
Significant controversy arose because residents and nurses had been
caring for his tracheostomy using N95 masks and face shields, but not
always with full PPE. The surgeons involved had to defend the ethics of
proceeding to surgery with a pending COVID-19 RT-PCR. All future mucosal
cases were subsequently required to have two tests with results
completed before surgery. Fortunately, our facility concurrently
acquired a rapid test with two-hour turnaround time, and a third test
performed on postoperative day 4 which returned negative. Given the two
negative tests, and absence of symptoms, it was decided that the second
test was likely a false positive. The patient spent only one night on
the designated coronavirus floor.
One member of the operative team, a “scrub” technician who entered the
procedure briefly, later became mildly symptomatic and tested positive
for coronavirus RT-PCR. Other members of the surgical team and nurses
and housestaff performing postoperative care all tested negative. The
origin of the exposure of our technician is difficult to determine.
The patient was discharged home on postoperative day 9 with a
nasogastric feeding tube and a tracheostomy tube with a plan to remove
both soon in the office. Final pathology revealed negative margins,
perineural invasion at the primary site, and a 9-millimeter lymph node
grossly involved by cancer at level 1B with extracapsular extension,
leading to a recommendation for chemoradiation postoperatively.