Airway management under VA-ECMO for severe tracheal invasion by thyroid carcinoma

Papillary thyroid carcinoma progresses slowly and carries a relatively good prognosis. However, invasion of important adjacent structures, such as the recurrent laryngeal nerve, trachea and esophagus, worsens the patient's QOL. While cases of thyroid carcinoma invading the trachea are sometimes encountered, cases of advanced thyroid carcinoma are raraly encounterd in which tracheal intubation is impossible. While performing surgery in these cases, sufficient consideration should be given before the operation to methods for maintaining the airway. Herein, we report a case of thyroid carcinoma invading the trachea, in which tracheotomy needed to be performed under extracorporeal membrane oxygenation (ECMO). A 70-year-old woman presented to a neighborhood doctor with a history of difficulty in breathing. CT showed severe tracheal invasion by a thyroid carcinoma, and the patient was referred to our hospital. A PET-CT revealed its metastases in the lung, liver, and bones. Biopsy of the tumor invading the trachea revealed the diagnosis of papillary carcinoma. Because the airway stenosis was severe, usual tracheal intubation, as well as usual tracheotomy and mediastinal tracheotomy, was difficult. Therefore, we incised the first and second tracheal rings not invaded by tumor and carried out intubation through the tracheotomy stoma. We used ECMO in anticipation of airway obstruction due to bleeding, and were therefore able to maintain the airway. Thereafter, we performed total thyroidectomy, D3c neck dissection, and tracheal fenestration. After the operation, radioactive iodine therapy was administered and the fenestrated trachea was closed by staged operations.