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.