Device implantation complicated by a retrosternal goiter

Central venous obstruction in the cardiac implantable electronic devices (CIED) population is commonly due to thrombosis and fibrosis secondary to the passage of pre-existing leads. However, vein occlusion before CIED implantation is uncommon, and one cause is retrosternal goiters. We report a case where the failure of the initial implantation of a primary CIED led to an unusual implantation route without goiter excision. The patient had an indication for cardiac resynchronization therapy (CRT) given his left ventricular (LV) function was impaired and had second-degree heart block Mobitz Type II; however, he had occluded bilateral subclavian veins due to a sizeable retrosternal goiter. This obstruction led to the implantation of a single lead pacemaker via the right femoral vein after multiple failed attempts at CRT, dual chamber pacemaker and left bundle branch area pacing (LBBaP).

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.

Extended cervical approach for retrosternal multinodular goiter

Objective

Partial or total sternotomy is required for 10% of retrosternal goiter. This study reviewed our experience with an extended cervicotomic approach as an alternative surgical solution for retrosternal goiter.

Methods

A retrospective study was performed on patients who underwent partial or total thyroidectomy for retrosternal goiter between 2014 and 2019 at a tertiary medical centre. Data on clinical, radiologic, and pathologic factors were analysed. Peri- and postoperative outcomes were compared between extended and standard cervical approaches to predict the need for an extended cervical approach.

Results

The cohort included 265 patients, of whom 245 (92.4%) were treated by standard thyroidectomy. In 17 (6.4%), the standard approach proved insufficient, and the horizontal incision was extended to a T-shape to improve access. The remaining 3 patients required a sternotomy. Use of the extended cervical approach was significantly associated with clinical features such as male gender, diabetes, high body mass index and postoperative hypocalcaemia.

Conclusions

The extended cervicotomic approach is an alternative surgical solution for retrosternal goiter, with no increased risk of significant post-operative complications.

Innovative trends in surgery: a robotic approach to retrotracheal goitre

The retrotracheal form is a rare variant of retrosternal goitre. The incidence is low, representing approximately 4% of all retrosternal goitres. The traditional approach to the treatment of this type of pathology is the cervical approach combined with high thoracotomy. Recently, however, new methods and technologies have begun to emerge that also open new possibilities for the surgical management of these conditions. The aim of this case report was to present the potential of a video-robotic approach in the treatment of retrotracheal goitre. The authors have successfully used this innovative method in the treatment of retrotracheal lesions, bringing hope for more effective and less invasive surgical interventions in this difficult-to-access area.

[Clinical application of retrograde thyroidectomy from top to bottom in retrosternal thyroid surgery]

Objective:To investigate the value of retrograde thyroidectomy from top to bottom in the operation of retrosternal thyroid surgery. Methods:Retrospective analysis was performed on the cases of retrosternal goiter excised by our surgeons from January 2017 to June 2022,the technical points, feasibility and advantages of the operation were summarized. Results:A total of 15 cases of retrosternal goiter treated by retrograde thyroidectomy were collected, including 5 cases of type Ⅰ retrosternal goiter and 10 cases of type Ⅱ retrosternal goiter.The postoperative pathology was benign. The surgical time is 40-60 minutes for unilateral retrosternal goiter and 70-90 minutes for bilateral goiter. All patients were discharged normally within 7 days after operation, and no operative complications were observed such as bleeding, hoarseness or hypoparathyroidism. Conclusion:This surgical excision method of thyroid is suitable for the type Ⅰ and type Ⅱ retrosternal goiter surgery, which can avoid the difficulties in exposing and separating the the inferior thyroid behind the sternum in conventional surgical method, speed up the operation and reduced the difficulty of operation, and has certain promotion value in clinic.

OUP accepted manuscript

The substernal goitre is defined as a goitre for which >50% of the mass is located below the superior orifice of the thorax, surgical resection remains the reference treatment, the approach used is the cervicotomy, which often allows to extract the mediastinal portion of the plunging goitre, and we report a rare case of a huge cancerous plunging goitre whose complete resection required the enlargement of the cervicotomy in right hemi-clamshell, for the carcinological, vascular and recurrent control.

Giant retrosternal goitre causing lung atelectasis

Not required for Clinical Vignette.

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.

An overview of retrosternal goiter

Goiters tend to grow slowly and steadily over many years, occasionally reaching the mediastinum and extending through the thoracic inlet into the visceral compartment. In most cases, retrosternal goiters originate from the cervical portion of the thyroid. The incidence of retrosternal goiters varies considerably, ranging from 0.2 to 45% of all thyroidectomies, depending on the criteria used to define this type of goiter. Symptoms are generally related to the compressive nature of the mass on the adjacent structures, and most patients report some form of respiratory manifestation associated with the goiter. A diagnostic assessment usually includes an evaluation of thyroid function, chest radiography, and computed tomography. Fine-needle aspiration biopsy should be avoided in substernal areas of the goiter due to limited visibility and location of vital structures in this region. Treatment of retrosternal goiters is surgical, as medical therapy is generally unsuccessful in these cases.

Retrosternal goiter in thoracic surgical practice

OBJECTIVE

To evaluate and optimize surgical approaches to the management of retrosternal goiter.

MATERIAL AND METHODS

A cohort retrospective single-center study included 56 patients aged 68.3±9.8 years with retrosternal goiter who underwent surgery between 2004 and 2019. Right-sided goiter was diagnosed in 16 cases, left-sided goiter in 21 patients, bilateral goiter in 19 patients. Palpable neck mass was found in 17 (30.4%), stridor in 16 (28.6%), thyrotoxicosis in 4 (7.1%) and recurrent laryngeal nerve palsy in 2 (3.6%) cases. X-ray signs of tracheal compression were detected in 43 (76.8%) patients, deviation in 26 (46.4%) patients. Resection through cervical collar incision was performed in 40 (71.4%) patients. Additional sternotomy was required in 11 (19.6%) patients, 1 (1.8%) patient required collar incision and right anterior mediastinotomy. Right-sided posterolateral thoracotomy without collar incision was performed in 1 (1.8%) patient with a suspected mediastinal teratoma. Three patients underwent median sternotomy only because of preoperative diagnosis of teratoma in one and thymoma in two patients.

RESULTS

There was no perioperative mortality. Transient vocal changes occurred in 3 (5.4%) patients, recurrent laryngeal nerve palsy in 3 (5.4%), atrial fibrillation in 2 (3.6%), wound complications in 2 (3.6%), left phrenic nerve palsy in 1 (1.8%), transient hypocalcaemia in 1 (1.8%) and persistent hypothyroidism in 1 (1.8%) patient. Hospital-stay ranged from 2 to 12 (5.5±2.0) days. Multinodular goiter was found in 53 (94.6%) patients, diffuse goiter in 1 (1.8%), ectopic thyroid in 1 (1.8%) and oncocytic tumor in 1 (1.8%) patient. One (1.8%) patient underwent simultaneous resection of RSG via a collar incision and right-sided VATS upper lobectomy for primary lung cancer. One (1.8%) patient also underwent simultaneous resection of RSG via collar incision and right-sided VATS subcarinal lymph node biopsy for coexistent lymphoma. Mean vertical length of goiter in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. Mean weight of specimens was 162.3 g in patients with collar incisions and 312.5 g in the sternotomy group. Sternotomy was required in 14 (25%) patients.

CONCLUSION

Resection of retrosternal goiter is more commonly performed via cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the need for sternotomy. Surgical outcomes are not affected by surgical approach. Simultaneous thoracic interventions for a coexistent pathology in patients with RSG may be considered. Further research of minimally invasive interventions for RSG resection is required.

Enlargement of Intrathoracic Goiter with Unilateral Phrenic Nerve Paralysis Leading to Cardiopulmonary Arrest

As an intrathoracic goiter expands, it causes airway stenosis and phrenic nerve paralysis, and slight respiratory stimuli can trigger sudden life-threatening hypoventilation. A 78-year-old obese woman with a large intrathoracic goiter was found unconscious with agonal breathing in her room early in the morning. Cardiopulmonary resuscitation restored spontaneous circulation. She underwent surgical removal of the goiter; however, she required long-term mechanical ventilation because of atelectasis due to phrenic nerve paralysis. In patients with large intrathoracic goiters, difficulty breathing on exertion and diaphragm elevation on chest X-ray may be significant findings predicting future respiratory failure.

To explore the risk factors and preventive measures affecting the treatment of retrosternal goiter: An observational study

The definition of substernal goiter (SG) is based on variable criteria, leading to considerable variations in the reported incidence (from 0.2% to 45%). The peri- and postoperative complications are higher in total thyroidectomy (TT) for SG than that for cervical goiter. This study aimed to evaluate the preoperative risk factors associated with postoperative complications.From 2002 to 2014, 142 (8.5%; 98 women and 44 men) of the 1690 patients who underwent TT had a SG. We retrospectively evaluated the following parameters: sex, age, histology, pre- and retro-vascular position, recurrence, and extension beyond the carina. These parameters were then related to the postoperative complications: seroma/hematoma, transient and permanent hypocalcemia, transient and permanent laryngeal nerve palsy, and the length of surgery. The results were further compared with a control group of 120 patients operated on in the same period with TT for cervical goiter (CG).Statistical analysis (Student t test and Fisher exact test) indicated an association between recurrence and extension beyond the carina with all postoperative complications. The group that underwent TT of SG showed a statistically significant higher risk for transient hypocalcemia (relative risk = 1.767 with 95% confidence interval: 1.131-2.7605, P = .0124, and need to treat = 7.1) and a trend toward significance for transient recurrent laryngeal nerve palsy (relative risk = 6.7806 with 95% confidence interval: 0.8577-53.2898, P = .0696, and need to treat = 20.8) compared with the group that underwent TT of cervical goiter. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina.TT is the procedure to perform in SG even if the incidence of complications is higher than cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina.

Retrosternal goiter

INTRODUCTION

Retrosternal goiter is an enlarged thyroid mass of which more than 50% is located in the mediastinum. Indications for surgery of retrosternal goiter include ineffective pharmacological treatment, mechanical syndrome, suspicion of malignancy and thyrotoxicosis. Computed tomography is the gold standard in the diagnosis of retrosternal goiter. The surgery can be performed from a cervical incision, using sternotomy or thoracotomy.

METHODS

The aim of our study was to evaluate our own group of retrosternal goiters. In 2011-2019, 1739 thyroid surgeries were performed at the 3rd Department of Surgery, University Hospital Motol, Prague. We retrospectively followed the age, gender, retrosternal spreading, postoperative complications (especially hypocalcemia, bleeding and dysphonia) and the definitive histological finding.

RESULTS

Retrosternal goiters were presented in 202 (19.2%) of the total of 1739 thyroid surgery patients. Sternotomy was performed in 31 patients. Women (61%) predominated over men (39%). The mean operating time was 125 minutes. We did not detect any serious postoperative bleeding necessitating surgical revision. Temporary hypocalcemia was observed in 10 patients (32%) based on laboratory testing. Unilateral iatrogenic vocal cord paresis was observed in 6 patients (19.4%) and was permanent in 3 patients (9.3%). One patient passed away soon after the operation, nevertheless the death was related to a simultaneously planned cardiothoracic procedure.

CONCLUSION

The retrosternal goiter can be removed using the cervical approach in most cases. Total thyroidectomy using sternotomy is associated with higher morbidity and mortality, higher blood loss and longer hospital stay; nevertheless, it does not increase the risk of long-term postoperative complications. Procedures requiring sternotomy or thoracotomy should be done at centers experienced in these types of procedures.

Ultrasound-Guided Percutaneous Microwave Ablation for Substernal Goiter: Initial Experience

OBJECTIVES

To preliminarily evaluate the safety, effectiveness, and feasibility of microwave ablation (MWA) for substernal goiter (SSG) in select patients and to provide a relevant treatment reference for further studies.

METHODS

From April 2017 to December 2017, 10 patients with SSG were treated by MWA. All patients were followed for at least 3 months to observe the therapeutic effects and complications. Therapeutic effects were assessed at follow-up for the relief of patients' symptoms, resolution of the cosmetic grade, and volume reduction rate (VRR) of SSG. Possibly related factors for the 3-month VRR of the nodules were analyzed.

RESULTS

The study included 9 female patients and 1 male patient with a mean age ± SD of 56.8 ± 10.1 years (range, 34-70 years). The mean volume of the nodules was 52.9 ± 27.9 mL (range, 23.7-122.6 mL). The nodule volume was significantly reduced at the 3-month follow-up (17.5 ± 9.5 mL; P < .05). The mean 3-month VRR of the index nodule was 66.7% ± 7.1%. A higher ablated portion-to-nodule ratio 1 day after MWA predicted a higher 3-month VRR (Spearman r = 0.646; P = .044). The mean symptom score (from 4.5 ± 1.7 to 1.5 ± 1.0; P = .005) and cosmetic grade (from 3.3 ± 0.5 to 2.2 ± 0.4; P = .004) declined significantly 3 months after the procedure. No complications or unexpected side effects were observed.

CONCLUSIONS

Our preliminary results support the effectiveness and safety of MWA for local control of SSG. This technology can be applied in select patients with SSG who are ineligible for surgery.

Extracorporeal membrane oxygenation for the anesthetic management of a patient with a massive intrathoracic goiter causing severe tracheal obstruction with positional symptoms: A case report

INTRODUCTION

Perioperative anesthetic management in cases of severe airway obstruction with positional symptoms can be associated with difficulties in ventilation or intubation, with a risk of acute respiratory decompensation at every stage of anesthesia.

PATIENT CONCERNS

Here we describe the anesthetic management of a 67-year-old man with a massive intrathoracic goiter causing severe tracheal obstruction with positional symptoms. The patient presented with progressive dyspnea that was aggravated in the supine position and was scheduled for total thyroidectomy.

DIAGNOSIS

Preoperative computed tomography showed a large goiter extending into the thoracic cavity, with diffuse segmental tracheal narrowing for 6 cm. The diameter at the narrowest portion of the trachea was 4.29 mm.

INTERVENTIONS

Before the induction of general anesthesia, we applied extracorporeal membrane oxygenation (ECMO) in preparation for potential difficulties in securing the airway during general anesthesia. Subsequently, anesthesia was successfully induced and maintained.

OUTCOMES

After the surgical procedure, fiberoptic bronchoscopy and chest radiography showed resolution of the tracheal narrowing. ECMO was weaned 2 hours after the surgery, and the patient was extubated on the first postoperative day. He was discharged without any complication.

CONCLUSION

The findings from this case suggest that the use of ECMO before the induction of general anesthesia is a safe method for maintaining oxygenation in patients with severe tracheal obstruction.

Surgical approach to the substernal goiter

Surgery for substernal goiters can be technically demanding. Extensive mediastinal extension brings the thyroid gland into close quarters with vital intrathoracic structures. Proper preoperative planning is required to determine the potential need for an extracervical approach. Assessing the risk of requiring an extracervical approach is typically based on findings from cross-sectional imaging of the neck and chest. This article addresses the important anatomical considerations when resecting a large substernal goiter and also reviews various extracervical approaches.

[Giant Intrathoracic Goiter Requiring Emergency Airway Management;Report of a Case]

An 81-year-old woman with acute respiratory distress was referred to our hospital. Computed tomography showed a large mass in the upper mediastinum with severe tracheal stenosis. Endotracheal intubation was performed under the preparation of extracorporeal membrane oxygenation and high-frequency jet ventilation, and the tumor was completely removed. The pathologic diagnosis was a goiter. Post-operatively, respiratory distress disappeared. No tumor recurrences have been noted for more than 2 years after surgery.

Substernal Goiter: Correlation between Grade and Surgical Approach

Substernal goiter is defined as a thyroid growth beyond the thoracic inlet. Using the cross-section imaging CT system, it can be classified into three grades. The aim of the study was to validate the surgical approach and the occurrence of postoperative complications with substernal goiter extension in our patient population. From a total of 1145 patients who underwent thyroid surgery at our institution in a 15-year period, 60 patients with substernal goiter were included. Clinical features and demographics, degree of extension, surgical details, and complications were analyzed. Mean ± SD age of the patients was 58 ± 14.7 years and 88 per cent were females. According to the cross-section imaging CT system 61.7 per cent were grade I, 23.3 per cent grade II, and 15 per cent grade III. Total thyroidectomy was performed in 78.3 per cent of the patients, subtotal thyroidectomy in 18.3 per cent, and lobectomy in 3.3 per cent. The cervical approach was sufficient to perform 96.7 per cent of the thyroidectomies, requiring partial sternotomy in only two patients with grade III substernal goiter. Patients with grade III substernal goiter had a higher risk for postoperative dysphonia (OR = 14.29, IC95% 1.14-178.9, P = 0.03), which occurred in three patients (two transient and one permanent). Transitory hypoparathyroidism was present in 20 patients (33.3%) and did not correlate with goiter extension. Most substernal goiters can be resected through a cervical approach, with relatively low morbidity. Postoperative dysphonia was directly related to the extension of the goiter. Few cases with grade III goiters require a partial sternotomy.

Cancer Frequency in Retrosternal Goiter

Retrosternal goiter prevalence is 5 to 40 per cent according to classifications in goiter series. Goiters with mediastinal extension were reported to be related with higher cancer rates. In our study, we aimed to investigate whether cancer incidence increased in retrosternal goiters compared with the cervical ones. Three hundred and ninety consecutive patients, who had surgery because of retrosternal goiter in Istanbul University Medical Faculty Department of General Surgery between 2005 and 2015 were included in the study (Group 1). Control group included 880 patients who had surgery because of nontoxic multinodular goiter in the same period (Group 2). Preoperative ultrasonography (USG) was performed to each patient. Fine-needle aspiration biopsy was performed in suspicious nodules and results were recorded. Carcinomas in histopathological examination were classified as intrathorasic and extrathorasic. Diagnostic rates of USG results were compared with histopathologic cancer results. Papillary carcinoma was diagnosed in 76 patients with retrosternal goiter (19%) and in 200 patients in the control group (22%). No statistically significant difference was detected between groups regarding the tumor rates (P > 0.05). One hundred and forty-four tumoral foci were detected in 76 patients with papillary carcinoma in retrosternal goiter patients. Three hundred and seventy tumoral foci were detected in 200 patients with papillary carcinoma in the control group. In the retrosternal goiter group, 104 carcinoma lesions of 144 papillary carcinomas were intrathorasic (72%). No statistically significant difference was detected between intrathorasic (2.1 ± 1 cm) and extrathorasic regiones (1.9 ± 0.8 cm) regarding the tumor size P > 0.05. When patients with and without cancer in the retrosternal goiter group were compared regarding familial thyroid cancer history, radiation to the neck, and cervical adenopathy, no statistically significant difference was detected. Cancer incidence of retrosternal goiters was not higher than that of the cervical ones. Yet, cancer foci of retrosternal goiters were commonly located in the intrathorasic area and were not detected with USG. Depending on these findings, we suggest that all retrosternal goiters should be surgically treated.

Tracheobronchopathia osteochondroplastica in recurrent retrosternal goiter. Surgical management

Tracheobronchopathia osteochondroplastica (TPO) is a rare pathology characterized by a progressive segmentary stenosis of the respiratory tract due to proliferation of osteocartilagineous nodules in the lumen of the distal part of the trachea and large bronchial trunks. Prognosis is usually benign, but some cases with an acute progression and a lethal outcome have been described. Clinical presentation is non specific, the chest x-ray is generally normal and there are not typical radiological signs of suspicion: diagnosis of TPO is usually incidental. We report a case of TPO associated with a retrosternal recurrent goiter. The CT scan conducted to evaluate the extension and the vascular relationships showed the characteristic lesions of the TPO with a segmental stenosis of the trachea greater than 70%. A bronchofiberoscopy confirmed the suspect of TPO. To date, the clinical studies carried out do not show a certain etiology, but all agree that chronic damage or chronic inflammations could be the cause of the onset of structural anomalies of the respiratory tract In literature, there is only a report which describes an association between TPO and thyroid pathology. It is obscure whatever these disease could be etiologically or fortuitously associated but a relationship cannot be completely excluded. Surgeons, anesthetists and radiologists which deal with thyroid pathology must recognize the disease, especially in the presence of bulky retrosternal goiters, to make a correct diagnosis and provide adequate perioperative management.

KEY WORDS

Mediastinal goiter, Osteocartilagineous Nodules, Tracheal Stenosis, Total Thyroidectomy, Tracheobronchopathia Osteochondroplastica.

Airway Obstruction Caused by Substernal Thyrotoxic Multinodular Goiter

BACKGROUND

Substernal thyrotoxic multinodular goiter (MNG) shows signs and symptoms as a result of compression of adjacent organs and thyrotoxicosis. However, acute airway obstruction is rarely caused by substernal thyrotoxic MNG.

CASE REPORT

We have described a 56-year-old Japanese woman who demonstrated acute airway obstruction because of compression of the airway by substernal thyrotoxic MNG. She had been diagnosed with substernal thyrotoxic MNG 6 years back. However, because she was unwilling to undergo surgery to remove substernal thyrotoxic MNG, she was treated with methimazole. The patient maintained normal thyroid function with this therapy for 6 years. However, after 6 years the patient was admitted to our hospital because of severe dyspnea. Physical examination revealed inspiratory stridor, which indicated an airway obstruction caused by substernal thyrotoxic MNG. Airway intubation and subtotal thyroidectomy were performed. After the surgery, the dyspnea ameliorated. The general condition of the patient remained good 6 months after the surgery.

CONCLUSION

This case clearly demonstrates the need for careful monitoring of substernal thyrotoxic MNG, because it may lead to an airway obstruction.

Delayed Presentation of Forgotten Thyroid Goiter - 25 Years After Thyroidectomy

Forgotten goiter is a rare occurrence (2 - 16% of retrosternal thyroid cases) that depicts recurrence of retrosternal thyroid mass due to growth of remnant thyroid tissue overlooked during an initial thyroidectomy. The patient is a 59-year female who presented with dyspnea and stridor 25 years after total thyroidectomy. She was diagnosed as having a mediastinal mass on radiographic imaging. There were only localized pressure symptoms due to mass effect. The mass was excised employing an extra-cervical approach and using a partial sternotomy. The profuse extension of thyroid tissue, adherent to vital structures in the thorax and the extra-cervical thyroidectomy was a novel experience. The mass was completely excised and the patient's symptoms alleviated after the surgery. The patient recovered without any complications and there was no recurrence at 1 year of follow-up.

Posterior Mediastinal Goiter

Most mediastinal goiters are retrosternally situated in the anterior mediastinal compartment. Posterior mediastinal goiters, either retrotracheal or retroesophageal, are rare. We herein describe a case involving a retrotracheal goiter in the right posterior mediastinum, which was excised using a combined cervico-partial sternotomy and right thoracotomy approach.

Transient hypoparathyroidism following thyroidectomy: A prospective study and multivariate analysis of 604 consecutive patients

Objectives

The purpose of this study was to identify the risk factors for postoperative transient hypoparathyroidism in a group of patients undergoing thyroid surgery.

Study Design

A prospective study was conducted on 604 patients undergoing thyroid surgery.

Subjects and Methods

Gender, final diagnosis, extent of resection, biology of pathology, intrathoracic involvement, surgery for recurrent multinodular goiter, and presence and number of parathyroid glands in a surgical specimen were analyzed as risk factors for postoperative transient hypoparathyroidism. The chi-square test and a logistic regression analysis were applied. RESULTS: On logistic regression analysis, only the extent of surgery constituted an independent variable for transient hypoparathyroidism ( P = 0.001).

Conclusion

The extent of surgery to central and/or lateral neck lymph nodes is responsible for a high rate of transient hypoparathyroidism owing to a high probability of unplanned parathyroidectomy or parathyroid gland devascularization.

An extended toboggan technique for resection of substernal thyroid goiters

We describe our technique for the safe resection of substernal thyroid goiters. Early mobilization of the thyroid gland from tracheal attachments anteriorly and laterally facilitates extraction of the goiter from the mediastinum. Retrograde dissection through the ligament of Berry on the ipsilateral side can also facilitate identification of the recurrent laryngeal nerve and delivery of the substernal portion of the gland. We describe 2 representative cases in which we successfully used this technique.

A limited thoracocervical approach for accessing the anterior mediastinum in retrosternal goiters: Surgical technique and implications for the management of head and neck emergencies

In this article we describe the surgical management of retrosternal goiters via a limited thoracocervical approach, and we explore how the respective surgical know-how can be used in the management of the carotid blowout syndrome. Four cases involving patients who had undergone thyroidectomy via a limited thoracocervical approach are retrospectively reviewed. An acute blowout of the innominate artery managed with the same principal surgical technique is also reviewed. Three patients had a total thyroidectomy and one had a hemithyroidectomy. No malignancy was found. There was no mortality or unexpected morbidity from the limited thoracocervical approach. The median length of the inpatient stay was 3 days. The blowout survivor lived for 9 months, with no rebleeding and with an acceptable quality of life. We conclude that a limited thoracocervical approach can be safely performed by head and neck surgeons for accessing the anterior mediastinum in retrosternal goiters, and the respective surgical know-how can be used in the immediate management of an acute carotid blowout syndrome with satisfying long-term results and provision of quality end-of-life care.

Postoperative Acute Respiratory Failure In Patients Treated Surgically For Goiters

The aim of the study was to present a clinical picture, treatment and prognosis regarding patients who developed acute respiratory failure (ARF) while treated surgically for a goiter.

MATERIAL AND METHODS

A total of 3810 patients were treated for goiters between 2008 to 2013. Symptoms of postoperative ARF were recognized in 39 (1%) patients.

RESULTS

Symptoms of postoperative ARF were a postoperative hemorrhage in 31 (79.4%), lymphorrhagia in 1 (2.6%), bilateral paralysis of recurrent laryngeal nerves in 6 (15.4%) and acute circulatory - respiratory failure in 1 (2.6%). Postoperative hemorrhage appeared in 19 patients operated for nodular goiter, 4 with a retrosternal nodular goiter, 1x nontoxic recurrent retrosternal nodular goiter, 1x toxic recurrent retrosternal goiter nodular goiter, 2x Graves'goiter and 4x with malignant goiter. The cause of hemorrhage was parenchymal bleeding from the stumps and / or short neck muscles (29x), arterial bleeding (1x) and bleeding into the subcutaneous tissue (1x). Massive lymphorrhagia appeared as a result of damage to the thoracic duct after total thyroidectomy due to papillary thyroid carcinoma with cervical lymph node dissection on the left side. All patients who were diagnosed with bilateral paralysis of RLN, tracheostomy was performed. Of all 39 patients who underwent surgery two died - one in 6 days after surgery due to myocardial infarction, and another as a result of micropulmonary embolism and acute circulatory - respiratory failure in 18 hours after surgery.

CONCLUSIONS

1. The most frequent causes of acute respiratory failure in postoperative period are a hemorrhage from the operation site and bilateral paralysis of recurrent laryngeal nerves. 2. Acute postoperative respiratory failure is an indication for postoperative wound revision.

Difficult thyroidectomies

The "difficult thyroidectomies" (DT) are motivated by several factors that, alone or in association with each other, make surgery more laborious and increase the related risks. Topographical, technical and anatomical criteria have been used by us to classify DT with a view to illustrating specific problems and suggesting appropriate strategies. According to topographical criteria we considered mediastinal goiter and resurgery; according to technical criteria we considered the presence of auto-immune thyroiditis and locally advanced malignancies; on the basis of anatomical criteria, we considered the presence of "non recurrent" laryngeal nerve and of a pre-operatory vocal cord palsy.

Tracheal varices caused by mediastinal compression of a large intrathoracic goiter: report of a case

INTRODUCTION

Tracheal varices are a rare condition but they can be an important source of massive or recurrent haemoptysis. Usually they are related to increased pressure in the pulmonary veins. Mediastinal goiter is often associated to compressive effects on the surrounding structures, including mediastinal vessels with potential superior vena cava syndrome.

CASE REPORT

We describe a case, not previously reported in literature, of mediastinal goiter with hemoptysis as first clinical manifestation. Bleeding was attributed to a superior vena cava syndrome associated to a tracheal fragile mucosa with an easily bleeding intramural nodule which was diagnosed as tracheal varices after total thyroidectomy. The nodule in fact disappeared together with the venous hypertensive signs after venous decompression of the mediastinum.

CONCLUSIONS

Compressive symptoms including tracheal varices, related to mediastinal goiter, can be treated surgically by total thyroidectomy via cervicotomy and when required with associated median sternotomy.

SURGICAL TREATMENT OF NECK AND RETROSTERNAL GOITER, CLINICAL CASE

Here is a clinical case of neck and retrosternal goiter. We describe the clinical course characteristics and diagnosis of cervical-retrosternal goiter, when intrathoracic goiter was not located by palpation.

Substernal goiter: when is a sternotomy required?

The presence of substernal goiter is, per se, an indication for surgical management. Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The aim of this study was to identify the preoperative predictors of a sternotomy in the management of substernal goiter in order to provide better preoperative planning and patient consent. Between 2005 and 2012, 665 patients were referred to our clinic for thyroidectomy, 42 patients (6.3%) had substernal goiter and were included in this study. All substernal goiters were treated surgically, 38 (90.5%) by a cervical approach and 4 (9.5%) by full median sternotomy. All surgeries were successful, with no major postoperative complications. Minor postoperative complications of transient hypocalcemia and transient paralysis of the recurrent laryngeal nerve occurred in 5 (11.9%) and 2 (4.7%) cases, respectively. Indication of median sternotomy was as follows: extension of goiter below the aortic arch, large thyroid tissue extending towards tracheal bifurcation, and ectopic thyroid tissue in the mediastinum. Substernal goiter can be removed through a cervical incision, but on rare occasions, a median sternotomy may be required.

[Experience of managing substernal goiter by totally endoscopic procedure]

To summarize the experience of managing substernal goiter by totally endoscopic procedure and evaluate the curative effect, we analysed eight patients diagnosed as substernal goiter type I and treated with totally endoscopic technique via central routing approach during March 2011 to June 2013 in Beijing Shijitan Hospital retrospectively. The feasibility, safety and curative effect of this surgical technique were estimated. All the cases were successfully operated with the totally endoscopic procedure, and the pathological result showed that 6 were goiter and the other 2 were minimal papillary carcinoma. None of the patients suffered from any complication, and the median follow up time was 6 months (1-28 months). The totally endoscopic technique is a feasible, safe and cosmic one for managing substernal goiter type I.

Pemberton's sign: explained nearly 70 years later

CONTEXT

Pemberton's sign is used to evaluate venous obstruction in patients with goiters. The sign is positive when bilateral arm elevation causes facial plethora. It has been attributed to a "cork effect" resulting from the thyroid obstructing the thoracic inlet, thereby increasing pressure on the venous system. According to some, the "cork effect" is caused by the thyroid descending into the thoracic inlet during arm elevation. According to others, the obstruction is due to elevation of the thoracic inlet against the thyroid.

OBJECTIVE

We studied a 36-year-old man with a positive Pemberton's sign secondary to a goiter extending to the substernal region.

DESIGN AND INTERVENTION

Clinical, biochemical, and radiological assessments were done. Magnetic resonance angiography of the neck was performed while the patient's arms were elevated and at his sides. After the imaging studies were completed, the patient underwent thyroidectomy.

RESULTS

Magnetic resonance angiography demonstrated that there was no craniocaudal movement of the goiter relative to the thoracic inlet. However, the lateral aspect of the clavicle moved medially and inferiorly, obstructing the right external jugular vein and subclavian vein confluence.

CONCLUSIONS

In the present case, we demonstrated that when eliciting Pemberton's sign, facial plethora and venous engorgement were due to the clavicles moving and compressing venous vasculature against the enlarged thyroid and not to a "cork effect." Rather, the clavicular motion observed during arm elevation could be compared to the movement of a "nutcracker" compressing major venous structures within a narrowed thoracic inlet against a relatively fixed and enlarged thyroid.

Is sternotomy always necessary for the treatment of mediastinal ectopic thyroid goiter?

Ectopic thyroid goiter accounts approximately for 1% of all substernal goiters and for 10-15% of all mediastinal masses. Sternotomy is generally accepted as the most adequate approach for the removal of ectopic thyroid goiters of the anterior mediastinum. We report two cases of mediastinal ectopic goiter removal through a cervical incision, without sternotomy. The technique is based on a careful and gentle traction of the mass by means of traction stitches and simultaneously on a blunt digital dissection, in order to exteriorize the lesion in the neck, as much as necessary to ligate its vascular pedicle before completing the removal. When performed with caution and precision, this approach can avoid sternotomy in selected patients with ectopic thyroid goiter.

KEY WORDS

Ectopic thyroid, Sternotomy, Thyroidectomy.

American Thyroid Association statement on optimal surgical management of goiter

BACKGROUND

Goiter, or benign enlargement of the thyroid gland, can be asymptomatic or can cause compression of surrounding structures such as the esophagus and/or trachea. The options for medical treatment of euthyroid goiter are short-lived and are limited to thyroxine hormone suppression and radioactive iodine ablation. The objective of this statement article is to discuss optimal surgical management of goiter.

METHODS

A task force was convened by the Surgical Affairs Committee of the American Thyroid Association and was tasked with writing of this article.

RESULTS/CONCLUSIONS

Surgical management is recommended for goiters with compressive symptoms. Symptoms of dyspnea, orthopnea, and dysphagia are more commonly associated with thyromegaly, in particular, substernal goiters. Several studies have demonstrated improved breathing and swallowing outcomes after thyroidectomy. With careful preoperative testing and thoughtful consideration of the type of anesthesia, including the type of intubation, preparation for surgery can be optimized. In addition, planning the extent of surgery and postoperative care are necessary to achieve optimal results. Close collaboration of an experienced surgical and anesthesia team is essential for induction and reversal of anesthesia. In addition, this team must be cognizant of complications from massive goiter surgery such as bleeding, airway distress, recurrent laryngeal nerve injury, and transient hypoparathyroidism. With careful preparation and teamwork, successful thyroid surgery can be achieved.

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.

Successful management of trachea stenosis with massive substernal goiter via thacheobronchial stent

A case of 65 year-old Chinese male patient with severe tracheal stenosis due to a massive substernal goiter, is presented. MRI and CT scan revealed that the massive substernal goiter was 9.3 × 6.1 × 4.7 cm in size, displacing the trachea and adjacent large vessels to the patient's right contributing to severe intrathoracic trachea compression up to 6 cm in length and the narrowest caliber of the trachea only 3.0 mm in diameter. To the best of our knowledge, optimal airway management for the massive substernal goiter resection was considered to be temporary tracheobronchial stent placement pre-operation.

Retrosternal goiters

The term of retrosternal or substernal goiter means that more than 50% of thyroid gland descends in the thorax.

MATERIAL AND METHODS

There is a retrospective study on retrosternal and substernal goiter and its patological features among 2482 patients who underwent thyroidectomy between 2000 and 2010 in the First Surgery Clinic of Iaşi. Retrosternal goiter was identified 54 patients (2.17%). All patients were refered to surgery from the Clinic of Endocrinology.

RESULTS

Mean age at diagnosis was 55.3 +/- 3.58 years, and most cases were found in women (83.3%). The clinical pictures of retrosternal goiter was dominated by compressive disorders. Thyroid function abormalities were identified by hormonal assays performed on Endocrinology Clinic lasi in 15 cases (27.7%). The diagnosis of retrosternal goiter was suggested by clinical examination and confirmed by imagery: thorax X ray, ultrasonography, CT scan. The cervical approach was being safely performed. Only in 8 cases (14,8%), sternotomy was necessary. There was no mortality and morbidity was 5.5% (3 cases). The length of stay in the hospital was 4.3 days. We compared our recent data with a previous report on retrosternal and thoracic goiter treated in First Surgery Clinic of lasi during 1950 to 1979 and published in the journal "Chirurgia" in 1981.

CONCLUSIONS

Retrosternal goiter is a particular form of thyroid surgical pathology presentation with declining incidence. Diagnosis and treatment of retrosternal goiter involve a multidisciplinary team. The endocrinologist has an important role in diagnosis and postoperative follow-up. Surgery is the treatment of choice for substernal goiters, but there are still some controversies on surgical approach, and complication rate. The cervical approach can be safely performed in almost all cases but when required, sternotomy should be performed without hesitation.

[The plunging goiter : about 43 cases]

BACKGROUND

The plunging goiter consists in a goiter whose lower limit is not palpable in surgical position.

AIM

To study the epidemiologic characteristics, the circumstances of discovery, the clinical signs, and the management of this disease.

METHODS

A retrospective study about 43 cases of plunging goiters operated during a period of 14 years in the ENT department of the hospital The Rabta Tunis.

RESULTS

The average age of our patients was 59.3 years. On physical examination, goiter was palpable in 41 patients (95.3%). The plunging character of the goiter was noted, at echography, in 26 patients. A cervico-thoracic scanner was performed in 41 patients (95.3%). It helped to confirm the plunging goiter in all patients. These goiters were most frequently pre vascular (73.2%) compared to the innomined venous trunk. The lower limits of the intrathoracic extensions were on the level of the superior vena cava in 4 cases (9.7%), on the level of the left brachio-cephalic venous trunk in 16 cases (39%) and on the level of the aortic arch in 15 cases (36,5%). The cervical incision was sufficient in 39 cases (97.5%) and we used a combined sternotomy in one patient (2.5%).

CONCLUSION

The plunging goiter is a thyroid tumour cervical originally descended, then developed, in the mediastinum. A good clinical examination and paraclinical can reach a definite diagnosis and to achieve better surgical.

Chylothorax associated with substernal goiter treated with transcervical thyroidectomy

BACKGROUND

Substernal goiters are frequently associated with compressive symptoms. Compression of the trachea and esophagus are common, whereas thoracic duct compression is a rare occurrence.

METHODS

We report a rare case of a 72-year-old woman with thoracic duct compression by a large substernal goiter that presented with shortness of breath. After undergoing thoracentesis multiple times, the patient was treated with thyroidectomy.

RESULTS

Transcervical thyroidectomy was performed without sternotomy. This led to resolution of her symptoms. Confirmation of chylothorax resolution was obtained with postoperative computed tomography of the chest.

CONCLUSION

Chylothorax is a rare sequela of substernal goiters. It can be managed with thyroidectomy. Sternotomy was avoided in this case.

Approach to management of the patient with primary or secondary intrathoracic goiter

Intrathoracic (substernal) goiter, depending on definition, is seen in up to 45% of all patients operated for goiter. It can either be primary (ectopic thyroid tissue detached from a cervical thyroid mass), which is very rare (1%), or (more commonly) secondary, where a portion of the goiter extends retrosternally. There is no consensus on diagnostic or therapeutic management, partly because many are asymptomatic. Classification involves functional characterization with serum TSH and morphological characterization with diagnostic imaging and cytology to rule out malignancy, which is not more common than in cervical goiters. Pulmonary function is often affected in asymptomatic individuals also. Therefore, but also because natural history is continuous growth and evolution from euthyroidism to hyperthyroidism, most experts recommend therapy. In primary as well as secondary intrathoracic goiter, the therapy of choice is total/near-total thyroidectomy and subsequent levothyroxine substitution. Data suggest that complications are only slightly more prevalent than in cervical goiters. Although levothyroxine is not recommended for goiter shrinkage, there is increasing focus on radioactive iodine as an alternative to surgery in secondary intrathoracic goiters. Here it can reduce thyroid size by on average 40% after 1 yr and improve respiratory function and quality of life. Recent studies show that recombinant human TSH, currently used off-label, can augment the radioiodine-related goiter shrinkage by 30-50%. With currently used doses of recombinant human TSH, the side effects, besides hypothyroidism, are rare and mild. Future studies should also explore the use of radioiodine in primary intrathoracic goiter and compare surgery and radioiodine, head to head.

[Intrathoracic goitre--undiagnosed--nevertheless operated]

A case review of a female patient, who was indicated for surgery for a goitre with minor bilateral retrosternal spread. The procedure included bilateral thyroidectomy during which the surgeon noticed unusual intrathoracic pathology in the left hemithorax, under the removed lobe. Postoperative chest x-ray and CT examinations revealed intrathoracic goitre, which was then removed during a following procedure. In the article, the authors discuss this uncommon pathology. Because of its uncommon location, the pathology was not detected on standard preoperative endocrinological examination. It was the follow up, postoperative examination, based on which the correct treatment was initiated.

Massive goiter with retrosternal extension encasing trachea and esophagus

Massive goiter with retrosternal extension may impose additional risk such as difficult intubation, tracheomalacia, and possibility of different incision and approach including sternotomy. We would like to report a case of massive goiter encasing major neck structures and how it was managed.