Posted by James
CASE 2
A 60-year-old postmenopausal woman presented with 10 months history of painless left breast mass that increased rapidly in size three months prior to presentation. There was an associated productive cough, which subsided with cough mixture. Patient was a known hypertensive on generic adalat, moduretic and canadian atenolol. There was no history of previous surgery. Family and social history was not contributory. Physical examination revealed a middle-aged woman who weighed 63 kg. Her pulse was 96 beats/min, full, regular and blood pressure was 140/90. Respiratory rate was 22 cycles/min. The chest was clinically clear with good air entry bilaterally. She had an enlarged firm left breast with inverted nipple and peau d’orange skin change. There was associated ipsilateral non-tender, matted axillary lymph nodes and a few discrete, firm, nontender contralateral axillary lymph node enlargements. Hematological and serum biochemistry results were essentially normal. However, radiological examination of the chest showed widespread cannon-ball metastasis in both lung fields (Figure 3). Abdominal ultrasound showed stones in the gall bladder but no evidence of metastasis in the liver. Electrocardiogram (ECG) showed left atrial enlargement. FNAC of the left breast mass and ipsilateral axillary lymph node was positive for malignant cells.
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Posted by James
The patient was sedated overnight with oral diazepam 10 mg and premedicated with another 10 mg diazepam orally just before being transferred to the theater on the morning of operation.
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Posted by James
Mastectomy is a common surgical procedure for breast malignancies. General anesthesia is traditionally favored for the operation. However, there are situations when general anesthesia may be considered unsuitable. Regional anesthesia was chosen for mastectomy in our patients due to compromised pulmonary status, resulting from widespread malignant infiltrations of the lungs.
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Posted by James
INTRODUCTION
The era of regional anaesthesia dates back to 1884 when Koller discovered the anesthesia properties of cocaine. Since then, the scope of regional anesthesia has continued to widen and clinicians have succeeded in gaining access to almost every nerve in the body. Consequently, patients who for one reason or another are considered unsuitable for general anesthesia may now have their operations done under regional anesthesia. Such was the situation with the two patients discussed in this report. Since the breasts are ectodermal organs, which arose as a modification of the sweat glands, they are more or less superficial structures, which can be isolated and selectively blocked for surgical excision. Combining intercostal nerves block with infraclavicular and midline subcutaneous infiltration with local anesthetic provided effective and reliable anesthesia for simple mastectomy in the two patients.
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Posted by James
The patient was brought to the operating room and placed in a semirecumbent position. A Nellcor Puritan Bernett multiparameter patient monitor was applied. The pulse was 120 beats/min, blood pressure was 100/70 mmHg and peripheral arterial oxygen saturation was 92%, with the patient breathing oxygen-enriched air. A peripheral intravenous access was established and 0.9% saline commenced. This was followed by bilateral superficial plexus block performed by a consultant anesthetist (first author) as follows: the midpoint of the posterior border of the sternomastoid muscle was identified. From this point, 15 ml of 0.375% bupivacaine with 1:400,000 epinephrine was infiltrated along the posterior border of the muscle, 3 cm cephalad and caudad, to block the superficial branches of the cervical plexus. A further 3 ml of the solution was also infiltrated superficially above the muscle to block the transverse cervical nerves. The block was performed on both sides of the neck using a size 21-gauge hypodermic needle. This procedure was well tolerated by the patient. Surgical anesthesia was demonstrated in 15 minutes. The patient was positioned supine with the head supported on a head ring and elevated by about 25°. The classical thyroidectomy positioning, with the head fully extended with the aid of a shoulder pad, could not be effected because this position worsened the patient’s respiratory distress.
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Posted by James
The occurrence of goiters causing airway obstruction is not new. As far back as 1821, Hedenus reported successful thyroidectomies in six patients for goiters, which he described as “suffocating.” Goiter still remains an uncommon cause of upper airway obstruction even today. This is particularly so in developing countries, where goiters are often neglected for long due to ignorance and lack of ready access to affordable medical services. However, when respiratory obstructive symptom does occur, it is usually insidious, intermittent and postural in manifestation, especially in bed at night, initially. Severe/life-threatening airway obstruction, as seen in our patient, is extremely rare. It is not clear why the airway obstruction in this patient suddenly worsened on admission. There was no histological evidence of hemorrhage into the thyroid gland. It could, however, be due to upper airway infection, resulting in edema and retention of secretions.
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Posted by James
A 65-year-old woman presented at the emergency unit of the University of llorin Teaching Hospital, llorin, Nigeria, with one-week history of progressively increasing degree of breathlessness. She had a 10-year history of a progressively increasing anterior neck swelling. She had noticed a rapid increase in the size of the swelling with associated nodularity within the proceeding eight months. About two weeks prior to presentation, the patient developed a productive (purulent) cough with hemoptysis. She had no previous history of any other significant illness or anesthesia. She had no allergies. Family and social history was not contributory. Physical examination revealed a chronically ill-looking patient with dyspnea, tachypnea (respiratory rate of 32 cycles/min and stridor. She was mildly pale, afebrile, acyanosed, anicteric and not dehydrated. Her pulse was nObeats/min and regular, and blood pressure was 120/90 mmHg. She had a huge firm, nontender multinodular goiter, measuring 20×14 cm, extending from the submandibular region to the suprasternal notch (Figure 1). The goiter was more pronounced on the left. The trachea was deviated to the right with the thyroid notch located about 12 cm from the midline. She had positive Berry’s sign (left) and positive Kocher’s sign. There were cervical, supraclavicular and bilateral axillary lym-phadenopathies. The chest was clinically clear with moderate air entry bilaterally. Examinations of the other systems revealed no abnormalities. A provisional diagnosis of giant malignant goiter causing upper airway obstruction was made. The patient was admitted for investigations and scheduled for early thyroidectomy on the surgeon’s next elective list, which was to be two days later. She was commenced on oxygen therapy by nasal cannula.
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