Tracheal Necrosis Following Radiofrequency Ablation of a Benign Thyroid Nodule
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LETTER TO THE EDITOR
Tracheal Necrosis Following Radiofrequency Ablation of a Benign Thyroid Nodule Laurens J. van Baardewijk1 • Menno L. Plaisier1 • Frank J. C. van den Broek2 Pleun C. M. Wouters van Poppel3 • Salih Kurban4 • Johan W. H. Kruimer1
•
Received: 31 July 2020 / Accepted: 18 August 2020 Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2020
To the editor, We would like to report a case of a 43-year-old woman who was referred for image-guided ablation of a thyroid nodule. There were symptoms of compression. On ultrasound examination, the right-sided nodule was found to be predominantly solid and had a volume of 38 ml (Fig. 1). Fine-needle aspiration cytology was benign. Under deep sedation, the nodule was ablated using a trans-isthmic approach and the moving-shot technique (18G RFA electrode, 10 mm active tip, AMICA, HS Hospital Service SpA). Ablation time was 80 min, and 163 kJ was applied. In the days that followed, there were progressive symptoms of an unpleasant taste, swelling, dyspnea, and intermittent fever. On post-procedural day 21, the patient was brought to the emergency department with dyspnea and stridor. She was intubated because of airway compromise. A CT scan showed a non-enhanced area in the thyroid that represented the ablation zone and contained multiple small gas bubbles (Fig. 2). Laryngoscopy revealed a narrowing of the trachea, without disruption of the wall. Initially, the symptoms were thought to be caused by edema. After four days
& Laurens J. van Baardewijk [email protected] 1
Department of Radiology, Ma´xima MC, PO Box 7777, 5500 MB Veldhoven, The Netherlands
2
Department of Surgery, Ma´xima MC, PO Box 7777, 5500 MB Veldhoven, The Netherlands
3
Department of Internal Medicine, Ma´xima MC, PO Box 7777, 5500 MB Veldhoven, The Netherlands
4
Department of Intensive Care, Ma´xima MC, PO Box 7777, 5500 MB Veldhoven, The Netherlands
of treatment with corticosteroids and anti-inflammatory drugs, the tracheal stenosis persisted. It was decided that a surgical exploration should be undertaken. After hemithyroidectomy, a necrotic perforation in the tracheal wall of 22 9 15 mm was unexpectedly identified (Fig. 3). After resection of the necrotic lesion, primary anastomosis was performed. Further follow-up was complicated by a transient vocal cord palsy and hypothyroidism that required substitutive therapy. To the best of our knowledge, this is the first published case of tracheal necrosis and perforation after image-guided ablation of the thyroid [1]. The necrosis could possibly be the result of unnoticed direct contact between the applicator and the trachea. In addition, it is likely that there was conduction of excessive heat from the overheated nodule to the trachea. In a study by Deandrea et al., 105 large volume thyroid nodules were successfully ablated with the application of 49 kJ, much less than the 163 kJ applied in our case [2]. Coughing has been reported during
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