Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach

Transcervical and robotic-assisted thoracoscopic resection of a substernal goiter

Several genetic and environmental factors contribute to the development of multinodular goitre. A transcervical surgical resection is recommended for larger goitres, though a minority of cases may require sternotomy or thoracotomy. We present a case of a posterior substernal goitre that was resected with combined transcervical and robotically assisted thoracic approaches. A woman in her 30s with an enlarging thyroid goitre elected to proceed with surgical resection. CT imaging demonstrated significant extension of the goitre into the posterior mediastinum and a staged approach was decided on. Both the initial transcervical thyroidectomy and the subsequent robotically assisted resection of the mediastinal portion were successful, without major complications. While most substernal goitres can be resected transcervically, certain rare anatomic features, such as extension into the posterior mediastinum, warrant consideration of a thoracic approach. Specifically, a robotic-assisted resection poses several advantages over traditional, more invasive approaches.

Clinical Characteristics and Predictors Related to the Progression of Multinodular Goiter Causing Tracheal Compression and Deviation: A Report of Two Cases and Review of the Literature

We describe the clinical course of two patients who developed tracheal compression and deviation by multinodular goiter (MNG). Case 1: A 66-year-old woman presented with thyroid swelling. Five years after the initial admission, she was diagnosed with hyperthyroidism by Graves' disease and increased bilateral thyroid lobes compressing the trachea. Thyroglobulin was elevated from 210 to 472 ng/mL. Case 2: A 52-year-old woman presented with thyroid swelling. Five years after the initial admission, the increased right lobe deviated the trachea and compressed the right recurrent laryngeal nerve. Thyroglobulin was elevated from 122 to 392 ng/mL. Two cases and literature review indicated that MNG with >50 mm, solid components, and extension to the mediastinum or paralarynx were risk factors of tracheal compression and deviation. Monitoring thyroglobulin elevation can help predict the clinical course.

Retrosternal Goitre: Anatomical Aspects and Technical Notes

Background and Objectives: surgery for substernal goitre is still debated in the literature, due to the wide range of surgical options. This article outlines the findings of our extensive experiences, which include 264 cases of patients with “goitre plongeant“, and compares postoperative complications, despite surgical approaches. Material and Methods: preoperative planning and anatomical landmarks are described to determine the potential need of a combined approach. The surgical procedure is described, along with some stratagems, to ensure that the operation is completed safely. A statistical analysis of complications and the length of stay, with a comparison of cervicotomy and combined access, was performed using the Pearson chi-square significance test. Results: 264 patients underwent thyroid surgery for substernal goitre. The Kocher incision was the surgical approach chosen in 256 patients (96.6%), while an accessory incision was performed in 8 patients (3.4%). The necessity to use a two-fold surgical access was linked to a higher rate of postoperative complications (p-value < 0.01). The average length of stay (LOS) for cervicotomy was 2 days (1−3 days), while the average LOS was 5 days (4−7 days) (p-value = n.s.) for combined access. Conclusions: cervicotomy should be the gold standard technique for exploring intrathoracic goitre with a digital dissection, which, in almost all cases, enables the externalization of the mediastinal portion associated. Sternotomy is related to a higher rate of complications, so it should be performed only in selected cases. Management in large-volume centres may be more appropriate.

Clinicopathologic Characteristics and Outcomes of Massive Multinodular Goiter: A Retrospective Cohort Study

BACKGROUND

Thyroidectomy for massive goiters is challenging because of the increased risk of tracheomalacia, combined sternotomy, postoperative morbidity, and mortality, whereas studies investigating the clinicopathologic characteristics, postoperative morbidities, and surgical outcomes of massive goiters are limited.

METHODS

Patients with goiters undergoing thyroid surgery between 2009 and 2019 were retrospectively reviewed. A total of 227 patients were enrolled and divided into massive goiter group and large goiter group according to the weight of the goiter. Clinicopathologic characteristics, postoperative morbidities, and surgical outcomes were compared between the two groups.

RESULTS

Seventy-four patients (32.6%) had a goiter weighing more than 250 g and 153 patients (67.4%) were categorized in the large goiter group. Compared to large goiter patients, massive goiter patients had higher rates of retrosternal extension (82.4% vs. 30.7%), combined sternotomy (12.2% vs. 1.3%), intensive care unit admission (25.7% vs. 7.2%), transient hypoparathyroidism (41.9% vs. 25.5%), and transient recurrent laryngeal nerve palsy (10.8% vs. 3.3%) as well as prolonged length of hospital stay (P < 0.05).

CONCLUSIONS

Massive goiter patients were at increased risk of combined sternotomy, intensive care unit admission, postoperative morbidities as well as prolonged length of hospital stay after thyroidectomy compared to large goiter patients, but most of them can be treated through a cervical approach with a favorable outcome.

Preoperative Evaluation of Substernal Goiter by Computed Tomography in the Extended Neck Position

Sternotomy is indicated when a goiter cannot be resected via a cervical incision, such as in the case of a substernal goiter extending beyond the aortic arch. In this article, we report a case of a large substernal goiter that was successfully removed using the cervical approach only. This is a case of a 68-year-old woman, diagnosed with goiter 20 years ago, who complained of a neck mass enlargement with associated cough. Pathological examination revealed no malignancy. Computed tomography (CT) scan showed an 11-cm thyroid mass reaching the level of the aortic arch. Preoperatively, we evaluated the substernal extent of the goiter via CT in the extended neck position to decide whether sternotomy was necessary. With the patient's neck extended, the goiter withdraws cranially above the aortic arch. The mass was then removed via the cervical approach without sternotomy. Preoperative CT in the extended neck position was thus deemed helpful in deciding whether or not sternotomy was required.

Substernal goitre presenting with upper and lower extremity oedema

Substernal goitre is characterised by compressive symptoms of the airway and oesophagus. Chronic, progressive symptoms usually result in surgical removal. We report a rare presentation of substernal goitre in a male in his early 70s who suffered from severe bilateral lower extremity (LE) lymphoedema, resulting in immobility and nursing home placement, and left upper extremity lymphoedema. Our initial assessment led to a filariasis work-up, which was negative, due to the patient's prior 2-year residence in India and service overseas. Chest CT scan revealed an incidental substernal goitre extending posterior to the left innominate vein and aortic arch to the level of the left mainstem bronchus. The patient underwent a left hemithyroidectomy via cervical excision and sternotomy and had an uneventful recovery with resolution of lymphoedema and mobility. Despite extensive literature regarding clinical presentations of substernal goitre, severe lymphoedema of the LE is not a well-established association.

Huge toxic goiter extending to the posterior mediastinum; Case report with literature review

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Retrosternal goiter is defined when the thyroid gland extends below the thoracic inlet.

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It causes compression over the respiratory and the digestive passages, or pressure over the superior vena cava.

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It needs surgical treatment in most patients and usually requires the combined cervical and the thoracic approach.

Introduction

Retrosternal goiter may occur in up to 7% of the cases, most of them extend to the anterior mediastinum, extension to the posterior mediastinum is very rare. It causes compression on mediastinal structures such as the trachea, the bronchi, the esophagus, and great vessels. The diagnosis is done mostly by CT scan. Most cases need surgery which is done by the combined cervical and the thoracic incisions.

Case presentation

A 70-year-old man had history of thyroid enlargement for 10 years which was hyper-functioning and controlled with medical therapy. For the last 2 months the patient was complaining from dyspnea especially during supine posture and dysphagia. CT-scan showed huge extension of the thyroid gland to the posterior mediastinum causing compression over the tracheal and the esophagus. Surgery done through both cervical incision and manubriotomy and the huge thyroid gland extracted. The patient had uneventful recovery with no postoperative complications.

Conclusion

Retrosternal goiter causes airway compromise in most patients. Surgery for such cases is a challenging procedure with higher rate of complications, CT-scan is the most single valuable tool in selecting patients for sternotomy before surgery but the final decision for sternotomy is best done during surgery. A team work between a thyroid surgeon and a thoracic surgeon has better results.

A Large Substernal Goiter that Extended to Both Sides of the Thorax

Most substernal goiters can be managed through the transcervical approach, but a sternotomy is required in some cases. This report is about a large substernal goiter, which was resected via a transcervical and full sternotomy approach. The patient was a 57-year-old female, who visited our hospital for surgical treatment for a large substernal goiter. Computed tomography of the neck and chest revealed that the substernal goiter extended to both sides of the thorax and had compressed the trachea. We performed total thyroidectomy safely via a transcervical and full sternotomy approach. No postoperative complications occurred, except transient hypocalcemia. A histopathological examination did not reveal any malignancy, and the lesion was diagnosed as an adenomatous goiter. Most substernal goiters can be managed through the transcervical approach, but a full sternotomy is required when a substernal goiter extends to both sides of the thorax and/or has a larger diameter than the thoracic inlet or airway constriction is revealed. A full sternotomy provides excellent exposure and can help reduce the risk of complications, such as recurrent laryngeal nerve palsy and injuries to major blood vessels.

Giant Cervical Goiter With Posterior Mediastinal Extension

Most cervico-mediastinal goiters are situated in the anterior mediastinal compartment, but according to the literature, 10–15 percent of them are located in the posterior mediastinum. Although most anterior mediastinal goiters can be removed by using the transcervical approach, cervico-mediastinal goiters in the posterior mediastinal may require additional extracervical incisions. We report the case of a huge cervico-mediastinal goiter extending from the neck retrotracheally to the posterior mediastinum. Surgical removal is the treatment of choice in such cases. We performed an operation using a transcervical and right posterolateral thoracotomy approach. Histopathological examination confirmed the diagnosis of a large toxic goiter. The patient recovered well and was discharged in one week. While most retrosternal goiters can be resected through a transcervical approach, those extending beyond the aortic arch are better dealt with by either sternotomy or thoracotomy. This report describes the use of transcervical and posterolateral thoracotomy with an excellent postoperative result.

Surgical treatment of substernal goiter: An analysis of 44 cases

OBJECTIVE

Substernal goiters are classified as primary or secondary intrathoracic goiters. Here, we report the diagnosis, symptoms, treatment, and postoperative complications of 44 substernal goiters (2 primary mediastinal goiter and 42 secondary mediastinal goiters).

METHODS

A retrospective chart review of 351 patients undergoing thyroidectomy at the Department of Otolaryngology-Head and Neck Surgery of the Tokyo Metropolitan Tama Medical Center. Between 2009 and 2015, 44 patients underwent surgery for substernal goiter.

RESULTS

The frequency of primary and secondary mediastinal goiters was 0.5% and 11.9%, respectively. The preoperative symptoms were neck mass, dyspnea, and dysphagia. Eight patients were asymptomatic. Thirty-nine patients had benign masses and 5 patients had malignant masses. Most patients were operated on for adenomatous goiters (52.2%). In ten cases beyond the aortic arch, the tumors were benign and there were eight cases of adenomatous goiter. All patients underwent a successful transcervical incision without sternotomy. Even the primary intrathoracic goiters were extracted after total thyroidectomy via the cervical approach without complications. Although one case showed unilateral recurrent nerve paralysis as a postoperative complication, phonetic function improved in 6 postoperative months. No instances of postoperative bleeding or definitive hypoparathyroidism occurred, and tracheostomy was not performed in any of the cases.

CONCLUSION

The cervical approach was safely performed in almost all substernal goiters without an extracervical procedure. Selected cases of primary mediastinal goiter may be excised via the cervical approach.

Surgical approach and technique in retrosternal goiter: Case report and review of the literature

BACKGROUND

Retrosternal goiter is defined as a thyroid mass of which more than 50% is located below the thoracic inlet. The aim of this study is to assess the retrosternal goiter surgically approach through a neck incision and analyze the surgical technique.

CASE PRESENTATION

The case reported by us used a single neck collar-shaped incision for huge retrosternal goiter with good outcome. The patient was surgically treated through a neck incision without the need for sternotomy or lateral thoracotomy. We did not observe definitive lesions in the inferior laryngeal nerve or definitive hypoparathyroidism.

CONCLUSIONS

Patients with retrosternal goiter can be safely treated surgically through a single neck incision, which is less trauma and recovery quickly.

Demographics, disparities, and outcomes in substernal goiters in the United States

BACKGROUND

Disparities distinguishing patients with substernal goiters from nonsubsternal goiters have not been thoroughly described.

METHODS

The National Inpatient Sample database was used to compare patients who underwent substernal thyroidectomy years 2000 to 2010 with those who underwent thyroidectomy for nonsubsternal goiter.

RESULTS

A total of 110,889 patients underwent thyroidectomy for goiter (5,525 substernal and 105,364 nonsubsternal). Substernal thyroidectomy patients were older, more likely to be Black or Hispanic and to have Medicare insurance. They had a higher comorbidity index, were more likely to be admitted emergently and to have postoperative complications such as hemorrhage/hematoma, pneumothorax, pulmonary embolism, and hypocalcemia/hypoparathyroidism. Furthermore, substernal thyroidectomy patients had 73% increased odds of death during admission than nonsubsternal thyroidectomy patients.

CONCLUSIONS

Substernal goiters present a distinct type of goiter with identifiable patient-level characteristics and an increased risk of postoperative complications and death. Earlier identification and treatment of goiters may allow earlier interventions at a stage when risks are reduced.

A case of mediastinal goiter treated surgically using a clavicle-lifting technique

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A thyroidectomy is indicated in all cases of mediastinal goiter because of the risks of airway obstruction, potential malignancy, tracheomalacia and invasion into the adjacent structures.

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The clavicle-lifting technique is a simple and safe technique that involves lifting the clavicles with a pediatric extension retractor (Kent Retractor Set, Takasago Medical Industry, Tokyo, Japan).

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The clavicle-lifting technique is a good surgical option for upper-mediastinal lesions such as mediastinal goiters and it obviates the need for a sternotomy.

Introduction

Mediastinal goiter is a benign disease, which is defined as a goiter with the greater portion of its mass lying below the thoracic inlet. It is controversial whether the cervical approach is the best approach for all mediastinal goiter surgeries.

Case presentation

A 71-year-old woman presented with respiratory discomfort during exertion. Computed tomography (CT) revealed a mediastinal goiter extending to the arch of the aorta. Surgical resection was performed using a clavicle-lifting technique. The excised specimen was 13 × 10 × 5 cm in size and weighed 220 g. The pathological diagnosis was nodular goiter.

Discussion

The clavicle-lifting technique is a simple and safe technique that involves lifting the clavicles with a pediatric extension retractor (Kent Retractor Set, Takasago Medical Industry, Tokyo, Japan). This is a good choice for surgery on upper mediastinal lesions such as mediastinal goiters as it obviates the need for a median sternotomy.

Conclusion

Although further study is necessary, it appears that a transcervical approach using the clavicle-lifting technique may be an acceptable treatment for mediastinal goiters that extend to the aortic arch.

An unusual recurrent bilateral posterior mediastinal goiter after subtotal thyroidectomy: Case report

INTRODUCTION

Surgical treatment of benign thyroid diseases need to be followed up closely, since recurrent thyroid nodules can be seen after subtotal thyroidectomy. Intrathoracic goiter (ITG) occurs in 10–30% of patients following subtotal thyroidectomy. In general these goiters are benign, having a malignant rate of only 2–22%. ITG grows slowly but steadily and in its process of development, it narrows the thoracic inlet by compressing the surrounding structures. Most of these can not located in the anterior mediastinum, others located in posterior retrovascular area. Bilateral posterior retrovascular goiters are very rare.

PRESENTATION OF CASE

We report a case involving a 61-year-old woman with history of gradual-onset dyspnea who was referred to us for evaluation of a large mediastinal mass. She had undergone bilateral thyroid lobectomy for a cervical goiter 10 years ago. The mass was removed successfully via median sternotomy without complication. The patient recovered well and was discharged in 1 week.

DISCUSSION

Most anterior mediastinal goiters can be resected through a transcervical approach, but if those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy.

CONCLUSION

Bilateral recurrent posterior mediastinal and retrovascular large goiters are better resected via sternotomy rather than lateral thoracotomy. The reason for that are the possibility of injury to large vascular structures and the difficulty of their management through lateral thoracotomy when cardiopulmonary bypass needed.

Best approach for posterior mediastinal goiter removal: transcervical incision and lateral thoracotomy

Surgical removal of intrathoracic goiter can be performed by a cervical approach in the majority of patients. Review of literature shows that experienced surgeons need to perform an extracervical approach in 2-3% of cases. In spite of surgical management of substernal goiter is well defined, there is little available information about surgical approach of intrathoracic goiters extending beyond the aortic arch into the posterior mediastinum. We report two cases and propose combination of cervical incision and muscle-sparing lateral thoracotomy for posterior mediastinal goiter removal. In such cases, we do not favour sternotomy as posterior mediastinum is inaccessible due to the presence of heart and great vessels anterior to the thyroidal mass that would lead to perform a perilous blind dissection. Based in our experience, transcervical and thoracotomy approach is indicated for a complete and safe posterior mediastinal goiter removal.

Complete excision of a giant thyroid goiter in posterior mediastinum

Intrathoracic goiter is commonly located in the anterior mediastinum. Here we report a case of a 58-year-old Chinese male in whom we successfully removed the intrathoracic goiter and eased his dyspnea by a right posterolateral thoracotomy approach. Posterior mediastinal thyroid goiter with mediastinal compressive symptoms is an indication of surgery.

Cervical leverage: A new procedure to deliver deep retrosternal goitres without thoracotomy

INTRODUCTION

Although most retrosternal goitres can be removed through a standard collar incision, some cases require extra-cervical incisions for complete resection. We report a new technique to remove large retrosternal goitres without extra-cervical incisions.

PRESENTATION OF CASE

We present two cases in which a US Army-Navy (Parker-Langenback) retractor was used to deliver large retrosternal components into the cervical incisions.

DISCUSSION

This technique is useful in cases where the retrosternal component extends beyond the reach of the exploring finger and a well-developed plane can be developed between the gland and surrounding tissue.

CONCLUSION

The cervical leverage technique allows removal of a large retrosternal component through a cervical incision, thereby avoiding the attendant morbidity of a thoracotomy or median sternotomy. It should not be used if there is suspected neoplastic disease, dense adherence to or invasion of surrounding intra-thoracic structures.

Retrosternal goiter located in the mediastinum: surgical approach and operative difficulties

Most retrosternal goiters are situated in the anterior mediastinal compartment, but according to the literature, 10-15% are located in the posterior mediastinum. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a huge posterior mediastinal goiter extending from the neck retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side and ending at the level of the lower part of the left cardiac atrium, nearly reaching the diaphragm. Surgical removal is the treatment of choice in such cases. We performed an operation using a transcervical and right thoracotomy approach. Histopathological examination confirmed the diagnosis of the large goiter. The patient recovered well and was discharged in 1 week.