Surgical management of a substernal goiter

Surgical Management of Substernal Thyroid Goiters

Substernal thyroid goiters can present with progressive symptoms involving compression of vital structures such as the esophagus, trachea, or large vessels. A multidisciplinary approach is critical when diagnosing and treating these patients. This article discusses patient presentation, workup, and management options for patients with substernal goiter as well as surgical pearls to minimize risk of complications.

Overview of Thyroid and Parathyroid Disease: The Otolaryngology Perspective

The management of thyroid and parathyroid pathology varies widely, with unifying goals of symptomatic control and mitigating patient morbidity. In general, surgery is indicated when addressing malignancy or when medical management is insufficient. Over the last few decades, treatment paradigms for patients with head and neck endocrine disease have shifted significantly as our understanding of disease processes has expanded and with the advent of numerous relevant technologies. Here we provide a general overview of thyroid and parathyroid disease that may be managed by the otolaryngologist, with attention to emerging strategies in diagnosis and treatment.

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.

Estimation of Chest Wall Attenuation of the Emissions from Iodine-123 in the Instance of Substernal Goiter: A Phantom Study

Objective: The underestimation of thyroid uptake measurements with iodine isotopes has been a generally accepted theory in patients with substernal goiter due to attenuation by the chest wall. The extent of this underestimation is not well known. In this study, we calculate the attenuation of the emissions from iodine-123 utilizing a cadaver chest wall with a thyroid probe in order to better understand the potential severity of this underestimation. Methods: A capsule of 11.1 Megabequerels (MBq) of iodine-123 was measured using a thyroid probe directly, in a standard neck phantom and behind a cadaveric chest wall that included the soft tissues and bony structures (sternum). Results: Using the thyroid probe, the calculated attenuation of the iodine capsule by the neck phantom was 18% and by the chest wall was 35%. Conclusion: Thyroid uptake in the case of substernal goiter may be underestimated by standard techniques using a neck phantom. The composition of the chest wall can vary greatly and substernal extent of the goiter would be difficult to calculate with a high level of accuracy on a routine basis. Direct comparison with a cadaveric specimen leads to similar issues but does give us a rough estimation of the extent of this issue. This study suggests that the attenuation by the chest wall can be substantial. Knowledge of the extent of the substernal component of the thyroid gland may be useful if the uptake measurement is used to calculate doses for the treatment of hyperthyroidism in patients with a substernal goiter.