Stridor – an unusual presentation of myxoedema

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Life-threatening upper airway obstruction can result from various causes. We describe a case report of undiagnosed hypothyroidism presenting with life threatening upper airway obstruction, altered sensorium and cardiac involvement. A 56-year-old male, initially admitted to the psychiatric ward with a 2-day history of paranoid delusions, hallucinations and insomnia, developed acute stridor, oxygen desaturation and agitation, and was referred to the anaesthetist for emergency airway management. On initial examination, oxygen saturation was 70% on air and he showed signs of a partially obstructed airway with inspiratory stridor. During transfer to the emergency theatre he became unresponsive and arrested. Resuscitation was commenced and spontaneous circulation and respiration returned on an attempt at intubation. In the emergency theatre, laryngoscopy following inhalational induction with sevoflurane in oxygen showed significant pharyngeal oedema, but a normal looking grade 2 view of glottis and the patient’s trachea was intubated with a size 7 tracheal tube. Fibreoptic bronchoscopy following intubation did not show any obvious tracheobronchial obstruction. Chest X-ray showed an enlarged cardiac shadow (Fig. 1). CT scan of the chest and echocardiogram confirmed a large pericardial effusion, but no external compression of the tracheo-bronchial tree. A subsequent ENT examination confirmed generalised oropharyngeal oedema of soft palate and floor of the mouth. Thyroid function tests showed low free T3 and T4 and elevated TSH. The patient was started on intravenous liothyronine 10 μg, followed by regular levothyroxine and steroids. Chest X-ray showing pericardial effusion. Hypothyroidism can be associated with variety of psychotic and affective disorders [1]. Untreated, it can lead to accumulation of mucopolysacchrides in various tissues, and such deposits in supra glottic structures will lead to soft tissue swelling and upper airway obstruction [2]. This will require immediate airway management and these patients can be treated successfully in the intensive care unit with intravenous and oral levothyroxine [3]. However, in order to avoid such airway emergencies, a high index of suspicion is essential for the early diagnosis of hypothyroidism, especially when encountered with acute mental state changes in obese patients.