SAT-379 - Life-Threatening Airway Emergency from Follicular Thyroid Carcinoma

Introduction: Life-threatening airway compromises from thyroid disease are uncommon. Acute airway obstruction due to thyroid disease accounts for approximately 1% of thyroid surgeries, underscoring the rarity of emergent presentations requiring urgent airway intervention or thyroidectomy. We present a rare case of acute airway obstruction caused by previously undiagnosed follicular thyroid carcinoma.

Case Presentation: A 30-year-old man with a medical history significant for hypertension, obesity, and schizophrenia presented with aggressive behavior and disorganized thoughts. He was admitted to the psychiatry floor for acute psychosis. Although his behavioral symptoms were improving, the hospital stay was complicated by stridor, severe shortness of breath and oxygen desaturation to 65% on room air. The patient required emergent endotracheal intubation and subsequently experienced a pulseless electrical activity cardiac arrest. Two cycles of cardiopulmonary resuscitation were performed, after which return of spontaneous circulation was achieved. Once stabilized, he was extubated but required immediate re-intubation due to stridor and recurrent hypoxemic respiratory failure. Subsequently, a computed tomography of the neck demonstrated a large, heterogeneously hypodense left thyroid mass measuring up to 5.2 × 6.0 cm in axial dimensions, extending inferiorly to the level of the clavicular heads. The mass exerted a significant mass effect on the trachea, displacing it posteriorly and toward the right. Evaluation for mass infiltrating tracheal wall was limited due to non-contrast technique and motion artifacts. He underwent emergent left hemithyroidectomy and tracheostomy creation. Pathology revealed follicular carcinoma, angioinvasive with one confirmed focus of venous invasion, measuring 2.5 cm. There was no extrathyroidal extension and surgical margins were negative. He recovered postoperatively and was successfully decannulated. He underwent completion total thyroidectomy few weeks later and its pathology was benign. He is currently undergoing evaluation for radioactive iodine therapy.

Conclusion: The case highlights a rare initial presentation of thyroid cancer. Acute airway obstruction from thyroid malignancy is exceedingly rare, with life-threatening airway compromise accounting for only approximately 1% of thyroid surgeries. The case highlights the difficulties that arise among patients with uncontrolled psychiatric illness where early symptoms could have been mistaken for exacerbation of underlying mental illness rather than organic pathology.

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