A 30 y.o. male presents with SOB, his friend says he "turned blue". Why is his trachea so severely narrowed?

 arrow points to the trachea; the answer is on the image below.

arrow points to the trachea; the answer is on the image below.

goiter2f.jpg

Our patient had a very large goiter with a substernal component.  His airway was severely narrowed and he was admitted to the ICU and placed on ECMO rather than trying to intubate him initially.  The thyroid was removed after a sternotomy and parathyroids were reimplanted.

A goiter is  most often caused often by low iodine intake. 29% of the world’s population  resides in areas where the soil is  deficient  in iodine.  These areas include Africa, eastern Europe, the Himalayas, the Alps and the Andes.  

 goiters in the Himalayas

goiters in the Himalayas

In the United States there are areas where the soil is deficient in iodine.  This led to maps of the regions where goiters are endemic;  the “goiter belt”. Many of these individuals are hypothyroid. 

goiter belt.JPG

In the 1920’s salt was iodized as well as chicken feed.  Milk cows were also treated with iodine.  So from 1971-74 iodine intake averaged 320 mcg/L. Subsequently, iodate conditioners were removed from bread and many cows were no longer treated.  There was a general reduction in salt and egg consumption because of concern about hypertension and cholesterol.  Kosher salt became popular which DOES NOT contain iodine.  As a result from 1988-94 consumption dropped to 145 mcg/L.   ( lactating women need 290 mcg/day) Other compounds which compete for iodine receptors include bromides ( in fire retardants), fluorides  and chlorides were found contaminating water supplies.  As a result the incidence of hypothyroidism is not dropping.

 cretinism(severe iodine deficiency in three children in the Congo

cretinism(severe iodine deficiency in three children in the Congo

Our patient was extubated and then had to be reintubated for tracheomalacia.  He was eventually extubated and was noted to have some vocal cord paresis ,however he was able to pass a swallow test and was discharged home on a regular diet.

Zimmermann MB, Jooste PL, PandavCX. Iodin-deficiency disorder. Lancet. 2008 Oct 4.372(9645):1251-62.

Zimmermann MB. Iodine deficiency in pregnancy and the effects of maternal iodine supplementation on the offspring: a review . Am J Clin Nutr. 2009 Feb. 89(2)668s-72s.

Caldwell KL, Miller GA, Wang RY, Jain RB, Jones RL. Iodine status of the US population , National Health and Nutrition Examination Survey 2003-4. Thyroid. Nov 18(11):1207-14.

DeGroot L, Abalovich M, Alexander EK, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012 Aug 97(8)2543-65.