A 10-year-old school patient, with no morbid history, consulted with a 9-month history of dysphagia, dysphonia and dyspnea on progressive exertion, which prevented him from continuing with his school choir.
The initial physical examination described was normal.
During 6 months he received treatment with inhaled corticosteroids in usual doses due to low suspicion of asthma, with no remission of symptoms.
Later, a more excited, whispered voice appeared, with greater respiratory difficulty and evident orthopnea.
The first chest X-ray revealed a bilateral interstitial miliary pattern of micronodular type.
In the cervical-thoracic region, there was a narrowing of the upper airway layer in «pencil shape». The first diagnosis was the possibility of an expansive vascular or neoplasic process.
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The night before her transfer, the girl presented apnea and cramping during sleep and was admitted to the Intensive Care Unit of the Hospital Clínico de la Pontificia Universidad Católica de Chile.
On admission, the following stood out: heart rate 120 x', respiratory rate 36 x', SatO2: 88-90% (environmental FiO2), intense decubitus, severe breathing difficulty, preferentially inspiratory neck access, worsened.
At the cervical level, a thyroid nodule of normal size (no goiter) with slightly increased consistency was observed.
Pulmonary examination was normal, with no pathological noises.
Due to the severity and severe limitation to inspiratory flow, the assessment of pulmonary function is not recommended.
A new cervicothoracic radiograph was performed which confirmed the initial findings.
Ultrasound was not performed, preferring to perform a helicate axial tomography (CAT) with upper vocal cord cut and compression without right mediastinum, which revealed the presence of extensive critical mass in the anterior cervical region.
Both lungs showed micronodules suggestive of lung metastases.
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Given the high risk of losing the upper airway at the time of anesthetic induction and the great anxiety of the child, a semi-conscious intubation was performed.
Total thyroidectomy, bilateral cervical lymph node dissection, partial resection of the esophageal wall, laryngeal cartilage and right recurrent laryngeal nerve were performed.
Due to the tumor involvement of both recurrent laryngeal nerves, tracheostomy was performed.
The postoperative evolution was satisfactory, allowing its mechanical ventilation exit after 24 h.
The anatomopathological study revealed a well-differentiated papillary thyroid carcinoma, with predominant follicular subtype, onset of radioiodine treatment for 3-4 weeks due to the presence of contrast medium administered in the CT scan.
The girl was admitted in good condition to another hospital for definitive cancer treatment.
Subsequently, endoscopic control after three weeks showed complete mobility of the left vocal cord, which allowed decannulation of the patient with recovery of approximately 60% of the tone of voice and without showing disorders of the sealant.
