ROLE OF POINT OF CARE

ULTRASONOGRAPHY IN EVALUATION OF
AIRWAY FOR PATIENTS POSTED FOR
THYROID SURGERY

Submitted for the degree of

MD ANESTHESIOLOGY

of

AIIMS RISHIKESH

2018-2021

DR. ANUP GANESHGOUDA PATIL

1
 Proforma for Registration of Thesis For

M.D. Anesthesiology (2018-2021)

AIIMS Rishikesh
Name of Candidate Anup Ganeshgouda Patil

Department Anesthesiology

Title of Thesis Role of point of care ultrasonography in evaluation of

airway for patients posted for thyroid surgery

Introduction Enclosed (p-8)

Review of Literature Enclosed(p-9)

Hypothesis Enclosed(p-10)

Aim and Objectives Enclosed(p-11)

Material and Methodology Enclosed(p-11)

References Enclosed(p-16 )

Annexure 1 Enclosed (Proforma)

Annexure 2 Enclosed (Patient Information Consent Form)

Annexure 3 Enclosed (Patient Information Sheet)

Guide Dr. D. K. Tripathy , Additional Professor , Anesthesiology

Co-Guide Dr. Ummed Singh , Assistant Professor , Anesthesiology

Co-Guide Dr. Amit Kumar , Assistant Professor , Otorhinolaryngology

Date: Signature of candidate

2
 REMARKS OF POST GRADUATE GUIDE

The thesis titled “Role of point of care ultrasonography in evaluation of

airway for patients posted for thyroid surgery” of Dr. Anup
Ganeshgouda Patil for registration in MD Anesthesiology course of All
India Institute of Medical Sciences, Rishikesh is hereby recommended
and forwarded for favor of approval.

Signature of the Guide

Dr DebendraTripathy

Signature of the Co-guide

Dr. Ummed Singh

Signature of the Co-guide

Dr. Amit Kumar

Date:

Place: Rishikesh

3
 REMARKS OF HOD
This is to certify that the work “Role of point of care ultrasonography in

evaluation of airway for patients posted for thyroid surgery” of Dr Anup

Ganeshgouda Patil for registration in MD Anesthesiology course of All

India Institute of Medical Sciences Rishikesh can be undertaken in

this Institute. The work shall be done under the regular monitoring of

guide.

This thesis is recommended and forwarded for approval.

Signature

(Prof (Dr.) Mukesh Tripathi)

Head Of The Department

Department of Anesthesiology
AIIMS, Rishikesh

Date:

Place: Rishikesh

4
Ref Number:-

To,

The Dean,

AIIMS Rishikesh

Veerbhadra Marg

Rishikesh

Subject: THESIS FOR M.D ANESTHESIOLOGY

Madam,

1. I have registered my name with AIIMS Rishikesh for M.D. /

(ANESTHESIOLOGY) under the guidance of Dr DebendraTripathy
Department of Anesthesiology for the session of 2018-2021.

2. The suggested topic of my Thesis is as follows:

“Role of point of care ultrasonography in evaluation of Airway for

patients posted for thyroid surgery”

The Protocol for my Thesis is attached as Appendix-1.

3. A copy of IEC clearance certificate is attached as Appendix-2.

4. It is requested that approval of the above-mentioned topic may

kindly be accorded.

Thanking you,

Yours faithfully,

Dr Anup G Patil

Place: Rishikesh
Date:

5
 Reference No:.……………………. Date: ………

REPORT OF ETHICS COMMITTEE

DEPARTMENT ANAESTHESIOLOGY

CANDITATE ADMISSION YEAR 2018

COURSE & SUBJECT MD- ANAESTHESIOLOGY

To,

Dr Anup Ganeshgouda Patil

Anesthesiology
AIIMS, Rishikesh

Sub: Thesis Protocol titled: “Role of point of care ultrasonography in

evaluation of Airway for patients posted for thyroid surgery”

Ref: - ………………………………………………….…………
(Letter/ Proposal of Student)

Dear Student,

The above-mentioned Thesis protocol “Role of point of care

ultrasonography in evaluation of airway for patients posted for thyroid
surgery” was discussed in the Ethics Committee meeting held
on……………………
Ethics Committee has unanimously approved your Protocol. This work
will be done under the guidance and supervision of your guide Dr
DebendraTripathy.

.…………………….…
Chairperson,
Ethics Committee

6
 ROLE OF POINT OF CARE
ULTRASONOGRAPHY IN EVALUATION OF
AIRWAY FOR PATIENTS POSTED FOR
THYROID SURGERY

7
 INTRODUCTION
Airway in a longstanding thyroid and parathyroid mass may be

distorted. This is because of compression of trachea by the enlarged

gland[1]. Vocal cord being another significant part of airway can also

be included in the thyroid disorders preoperatively and

postoperatively. Knowledge of preoperative vocal cord function is

important to patient counselling for postoperative complications `[1-2].

Because of thyroid mass effect there may be associated tracheal

deviation.

This makes airway management in thyroid and parathyroid surgeries

difficult[1]. To manage such airways a detailed evaluation and planning

is needed. Conventional type of methods evaluating airway consist of

clinical and radiological methods including X-ray and CT scan [2].

JUSTIFICATION: With the advancement of point of care

ultrasonography in recent publication suggest that, ultrasonography

can be used for evaluation of airway with added advantage of

ultrasound being non-invasive, real time ,in expensive and does not
[3-4]
expose the patient to radiation is an equivalent alternative .

8
 REVIEW OF LITERATURE
Difficulty with intubation may be caused by an enlarged thyroid gland

producing tracheal deviation or compression or both [1].

Ultrasonography assessment of airway preoperatively has emerged

as good alternative. Various supporting literature are as follows:

1.Cheng et al(2012) , studied the usefulness of ultrasonography as a

screening tool for preoperative assessment of vocal cord movement

during thyroid and parathyroid surgery in two phases. The authors

concluded that ultrasonography appears to be relatively accurate

method for assessing vocal cord movement in the preoperative

setting.

2.Meco et al(2015), made an observational study as thyroid gland

volume assessment by ultrasonography correlate with difficult

intubation. The authors concluded that volume of thyroid gland is not

correlated with the intubation difficulty score.

3.Woo et al(2016), studied the lateral approach laryngeal

ultrasonography for vocal cord evaluation . Midline or anterior

approach laryngeal ultrasonography has significant limitations as a

diagnostic tool in patients with prominent or calcified thyroid cartilage .

9
The authors concluded that the limitations of laryngeal

ultrasonography on male patients can be improved with lateral

approach technique .

HYPOTHESIS:
Point of care ultrasonography is an equivalent alternative compared to

other conventional modalities for accurately evaluating airway in

patients posted for thyroid and parathyroid surgery.

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 AIM AND OBJECTIVES

AIM:

To determine the accuracy of point of care ultrasonography airway

evaluation in patients posted for thyroid surgery.

PRIMARY OBJECTIVE:
To compare the accuracy of point of care ultrasonography for vocal
cord evaluation with standard of care.

SECONDARY OBJECTIVES:
1. Tracheal compression and deviation

2. Ultrasonography volume of thyroid gland

3. Dynamic evaluation of tracheal compression or expandability of

trachea.

4. Retrosternal extension of thyroid gland.

11
 MATERIAL & METHODS

STUDY DESIGN :

A cohort study will be conducted in the Department of

Anesthesiology, at the All India Institute of medical Sciences,

Rishikesh, over a period of 15-18 months. The informed consent will

be taken from all the patients before inclusion in the study. Patients

posted for thyroid and parathyroid surgeries will be assessed for

airway in the pre-anesthetic clinic with conventional methods. Patient

is later assessed with ultrasonography according to study protocol .

SAMPLE SIZE :

Based on previous study, prevalence of vocal cord palsy in patients

with thyroid and parathyroid diseases was accounted as 2.96%. Total

of sample size 152 will be required to achieve a power of 80% and an

alpha error of 0.05. The patient will be included in study who are

assessed with ultrasonography irrespective of findings. All the

collected data will be subjected to appropriate statistical analysis with

McNemar test and Chi-square test. Statistical significance is accepted

at P<0.05[2].

12
Inclusion criteria:

1. All the patients posted above 18 years of age posted for thyroid and

parathyroid surgery.

Exclusion criteria:

1. Patients refusing for informed consent.

METHODS:

Patients posted for thyroid and parathyroid surgery will require PAC

clearance done in pre-anaesthetic clinic. Patients in pre-anaesthetic

clinic will be assessed airway by conventional methods including

clinical examination, Mallampatti grading , x-ray neck and / or CT

scan. These patients will then be explained about the ultrasonography

examination and consent will be taken.

Ultrasonography examination will be performed by anaesthesiologist

having experience of airway ultrasound. The anaesthesiologist

performing airway ultrasound will be blinded from the conventional

airway assessment. The airway scan will be done as per the following

protocol.

i)Trachea: Using ultrasound probe placed transversely on the neck

starting from upper border of thyroid cartilage. Trachea will be

13
 traced with ‘connecting string of pearls’ technique. Trachea

deviation if found will be noted. Outer border of trachea will be

measured and if any compression, the level compression and

narrowest tracheal diameter will be noted.

ii)Vocal cord: Similar to tracheal examination, ultrasonography probe

will be placed transversely on the neck at the thyroid cartilage.

Thyroid cartilage will be used as an acoustic window. True vocal

cord appears as hyperechoeic compared to false vocal cord.

Normal vocal cord movement of abduction and adduction will be

seen on normal respiration findings will be noted. The vocal

cord will be assed using both anterior, left lateral and right lateral

scan.

iii) Thyroid volume: Using ultrasonography thyroid volume will be

calculated using ellipsoid formula (height *width*depth*0.524) for

each lobe .Findings of each lobe will be noted and calculated for

sum of two thyroid lobe. The retrosternal extension of thyroid gland

will be assessed.

iv) Mass compressing trachea will be gently maneuvered and the

tracheal dilation in the previously compressed trachea will be

noted.

All the ultrasound image will be saved in electronic format.

14
Statistical analysis :

Statistical analysis will be performed using Graph Pad Prism (version

5.0) software. The results will be presented as descriptive statistics ,

and summarised as mean( standard deviation) , median ,or number

(percentage), whichever appropriate. A P-value <0.05 will be

considered significant.

15
 REFERENCES:

1. Tripathi M . Goitre and Airway Control. World Journal of

Endocrinology Surgery. 2010;2(1):9-16.

2. Cheng SP, Lee JJ, Liu TP, Lee KS, Liu CL. Preoperative

ultrasonography assessment of vocal cord movement during thyroid

and parathyroid surgery. World Journal of Surgery. 2012

1;36(10):2509-15.

3. Meco BC, Alanoglu Z, Yilmaz AA, Basaran C, Alkis N, Demirer S,

Cuhruk H. Does ultrasonographic volume of the thyroid gland

correlate with difficult intubation? An observational study.

Revistabrasileira de anestesiologia. 2015 ;65(3):230-4.

4. Kundra P, Mishra SK, Ramesh A. Ultrasound of the airway. Indian

journal of anaesthesia. 2011 ;55(5):456.

5. Woo JW, Suh H, Song RY, Lee JH, Yu HW, Kim SJ, Chai YJ, Choi

JY, Lee KE. A novel lateral-approach laryngeal ultrasonography for

vocal cord evaluation. Surgery. 2016 1;159(1):52-7.

16
 PATIENT PROFORMA
STUDY:Role of point of care ultrasonography in evaluation of Airway for
patients posted for thyroid surgery.

Serial no: CR NO:

Date : Ward :
Name : Bed :
Age : Sex :
Diagnosis :
Plan :
ASA grade :
Type of Surgery :

ULTRASOUND FINDING OF AIRWAY

Vocal Cord Anterior scan

Visualized- Y/N, cord position _____________, cord movement- Normal/
Abnormal, If abnormal details _______________

Right lateral scan

Visualized- Y/N, cord position _____________, cord movement- Normal/
Abnormal, If abnormal details _______________

Left lateral scan

Visualized- Y/N, cord position _____________, cord movement- Normal/
Abnormal, If abnormal details _______________

Tracheal Transverse
structures
Sagital scan

Tracheal Diameter of normal tracheal ring

diameters Narrowest part of trachea (level) _______ Diameter ____ Change
of diameter with manipulation

Course of the Deviated to left/ Deviated to right/ any other abnormality______________

trachea

Volume and Volume-

extension of
thyroid Retrosternal extension- yes/no

17
PARTICIPANT INFORMED CONSENT FORM
(PICF)
(English)
Participant identification number for this trial:
Title of project: Role of point of ultrasonography in evaluation of
airway for patients posted for thyroid surgery.

Name of Principal Investigator: Dr Anup Ganeshgouda Patil

Mobile : 09738546400
The information regarding the study has been explained in detail to
me, in a language that I comprehend, and I have fully understood the
contents.
I understand that the information collected about me from my
participation in this research and sections of any of my medical notes
may be looked at by responsible individuals from AIIMS. I agree to
take part in the above study.

Date:
(Signatures / Left Thumb Impression) Place:
Name of the Participant :
Son / Daughter of :
Complete postal address:

This is to certify that the above consent has been obtained in my

presence.

------------------------------
Signatures of the Principal Investigator Date :
Place:
1) Witness – 1 2) Witness – 2

------------------------------ -----------------------------
Signature Signature
Name : Name :
Address: Address :

साझेदार सूचित सहमचत फॉमम (पी.आई.सी.एफ)

18
 ( हिंदी)

इस परीक्षण के लिए प्रलिभागी पहचान संख्या:

प्रिंसिपल इनवेस्टिगेटर का नाम: डॉ अनुप गणेशगोड़ा पाटिल

मोबाइल: 09738546400
अध्ययन के बारे में जानकारी मुझे विस्तार से समझाई गई है, एक भाषा में जिसे मैं समझता हूं, और मैंने सामग्री को पूरी
तरह से समझ लिया है।
मैं समझता हूं कि इस शोध में मेरी भागीदारी से मेरे बारे में एकत्र की गई जानकारी और मेरे किसी भी मेडिकल नोट के
अनुभाग एम्स से जिम्मेदार व्यक्तियों द्वारा देखे जा सकते हैं। मैं उपरोक्त अध्ययन में भाग लेने के लिए सहमत हूं।

                                                                                 तारीख:
(हस्ताक्षर / बाएं थंब इंप्रेशन) प्लेस:
प्रतिभागी का नाम:
पुत्र / बेटी:
पूरा डाक पता:

यह प्रमाणित करना है कि उपर्युक्त सहमति मेरी उपस्थिति में प्राप्त की गई है।

------------------------------
प्रिंसिपल अन्वेषक तिथि के हस्ताक्षर दिनांक:
                                                                         जगह :

1) साक्षी - 1 2) साक्षी - 2

------------------------------ -------------------- ---------

हस्ताक्षर हस्ताक्षर
नाम : नाम :
पता : पता :

PARTICIPANT INFORMATION SHEET

Dear Patient/guardian of ....................................................

We are conducting a study at the All India Institute of Medical Sciences to COMPARE
ACCURACY OF POINT OF CARE ULTRASONOGRAPHY IN AIRWAY EVALUATION FOR
PATIENTS POSTED FOR THYROID SURGERY WITH STANDARD CLINICAL
PRACTICE.Patient/guardian is invited to take part in the study. You are requested to go
through the following paragraphs:
19
 I) Title: Role
of point of ultrasonography in evaluation of Airway for
patients posted for thyroid surgeries

ii) Purpose of the Study: The aim of our study is to determine the accuracy of point of
ultrasonography for airway evaluation compared to standard clinical practise.

iii) Methodology: If you agree to participate in this study, you will be assessed using
ultrasonography of neck after your routine pre-anaesthetic check-up . During the
procedure and study period you will be monitored according to the standard
guidelines of the Institute. If any side effects will be treated accordingly.

iv) Any risk to the subject associated with the study: no risk regarding this study

v) Confidentiality: All the records will be confidential and the patient’s identity would be
known to the chief investigator and would not be released to anybody else.

vi) Provision of free treatment for research related injury: No research related injury
is expected. If any complication does occur, you will be provided free treatment by the
hospital.

vii)Compensation of subjects for disability or death resulting from such injury: No

disability or death is expected from the study.

viii)Freedom of individual to participate and to withdraw from research at any time

without penalty or loss of benefits to which the subject would otherwise entitled:
Participation in the study is voluntary. Refusal to participate will not influence care of the
participants in this hospital in any way.

ix)Costs and Source of investigations and drugs: You will not be charged anything for
anything else related to this study project.

Available information sources: In case of any doubt regarding the study or any
emergency, you are welcome to contact the undersigned personally or over
telephone.

Dr. Anup Ganeshgouda Patil Dr DebendraTripathy

Junior Resident Additional Professor
Department of Anaesthesiology, Department of Anaesthesiology
AIIMS, Rishikesh. AIIMS, Rishikesh
साझेदार सूचना पत्र
लप्रयरोगी / अलभभावक ......................................... .......

हमऑि इंलडया इंस्टीट्यूट ऑफ मेलडकि साइंसेज में अध्ययन कर रहे हैं िालक मानक स्टिलनकि प्रैस्टिस के साथ थ्रॉइड सजषरी के लिए पोस्ट लक
एगए रोलगयों में अल्ट्रासोनोग्राफी एयरवे मूल्ांकन के अंक कीसटीकिा की िुिना की जास के ।अध्ययन में भाग िेने के लिए रोगी / अलभभावक को
आमंलत्रि लकया जािा है।आपको लनम्नलिस्टखि अनुच्छेदों से गुजरने का अनुरोध लकया जािा है:

20
I) शीर्षक: थायरॉइड सजषरी के लिए पोस्ट लक एगए मरीजों के लिए वायुमागष के मूल्ांकन पर अल्ट्रासोनोग्राफी के भूलमका |

ii) अध्ययन का उद्देश्य: हमारे अध्ययन का उद्देश्य मानक नैदालनक अभ्यास की िुिना में वायुमागष मूल्ांकन के लिए अल्ट्रासोनोग्राफी के ल ंदु
की शुद्धिा लनधाषररि करना है। iii) पद्धलि: यलद आप इस अध्ययन में भागिेने के लिए सहमि हैं, िो आपको पूर्व एनेस्थेहिक चेकके बाद
अल्ट्रासोनोग्राफी सेआप को अध्ययन लकया जाएगा । प्रलिया और अध्ययन अवलधके दौरान संथथान के मानक लदशालनदेशों के अनुसार आप पर
नजर रखी जाएगी। लकसी भी दुष्प्रभाव के अनुसार इिाज लकया जा एगा। iv) अध्ययन से जुडे लवर्य के लिए कोई जोस्टखम: इस अध्ययन के सं
ंध में कोई जोस्टखम नहीं है

v) गोपनीयिा: सभी ररकॉडष गोपनीयहोगंे और रोगी की पहचान मुख्यजांच किाषको जानी जाएगी और लकसी और को ररहा नहीं लकया
जाएगा।

vi) शोध से सं ंलधि चोट के लिए लन: शुल्क उपचार की व्यवथथा: कोई शोध सं ंधी चोट की उम्मीद नहीं है। यलद कोई जलटििा
होिी है, िो आपको अस्पिाि द्वारा लन: शुल्क उपचार मुहै या कराया जाएगा।

vii) ऐसी चोट से होनेवािी लवकिांगिा या मृत्यु के लिए लवर्यों का मुआवजा: अध्ययन से कोई लवकिांगिा या मृत्यु की उम्मीद नहीं है।

viii) लकसी भी समय जुमाषना या िाभ के नुकसान के ल ना व्यस्टिगि रूप से भाग िेने और अनुसंधान से वापसिेने के लिए स्विंत्रिा की
स्विंत्रिा: लवर्य में अन्यथा हकदार होगा: अध्ययन में भागीदारी स्वैस्टच्छक है ।भाग िेने से इंकार करने से इस अस्पिाि में लकसी भी िरह से
प्रलिभालगयों की देखभाि प्रभालवि नहीं होगी।

ix) जांच और दवाओं की िागि और स्रोि: इस अध्ययन पररयोजना से सं ंलधि लक सीऔर चीज के लिए आपसे कु छ भी शुल्क नहीं लिया
जाएगा।

एक्स) उपिब्ध सूचना स्रोि: अध्ययनया लकसी आपािस्टथथलि के सं ंध में लकसी भी संदेह के मामिे में, आप व्यस्टिगिरूप से या टेिीफोन पर
हस्ताक्षर लकएगए संपकष से संपकष करने के लिए स्वागि करिे हैं।

डॉअनुपगणेशगोडापालटि डॉदे ेन्द्रलत्रपाठी

जूलनयर लनवासी

अलिररिप्रोफे सर

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एनेथथेलसयोिॉजीलवभाग एनाथथेलसयोिॉजील

22