1267 Severe Obstructive Sleep Apnea in Patient with Large Multinodular Goiter. (27th May 2020) - Macias, Maria
Abstract: Introduction: Obstructive sleep apnea (OSA) is characterized by upper airway narrowing or closure during sleep. Age and obesity are common contributors, but large thyroid goiters have also been shown to contribute to OSA. Report of Case: We report a case of a 65 year-old-man (BMI 47 kg/m2) who presents with dyspnea and intolerance to PAP therapy. He had a slowly progressive goiter which was first noticed at age 45. He declined thyroidectomy due to concern of complications. A recent CT reported markedly enlarged thyroid (right thyroid lobe 10.9 x 8.5 cm, left thyroid lobe 7.0 x 6.5 cm and thyroid isthmus 4.0 cm). It had extension into the superior mediastinum and circumferential encasement of the subglottic trachea with effacement involving the lateral walls. In past, he was non-tolerant with BPAP therapy due to high pressure settings (24/14 cm water). Multiple attempts to desensitize were not successful. Most recent diagnostic polysomnography reported an apnea hypopnea index (AHI) of 35.2/ hour, oxygen nadir of 77%. Supplemental oxygen was titrated upward to 5 LPM due to persistent oxygen desaturations in the absence of obstructive events. In the PAP titration study, despite multiple efforts and patient's poor tolerance, the titration study was suboptimal. He was titrated to BPAP 15/11 and still had a residual AHI of 28.4/hour. Considering these findings thyroidectomy was again discussed which could potentially reduce OSA severity significantly. After long discussion, unfortunately the patient declined this recommendation. Other surgical options such as hypoglossal nerve stimulation was not technically feasible due to large goiter. Ultimately, he decided to remain on nightly supplemental oxygen. Conclusion: Large multinodular goiters with retropharyngeal extension can worsen obstructive sleep apnea and pose unique diagnostic and therapeutic challenges. In this case, thyroidectomy may have led to improvement of degree of sleep disordered breathing.