Abstract
Since substernal goiter first being described by Haller in 1749, a consensus on the definition of this entity has not been ensured, yet. Despite substernal goiter or retrosternal goiter is delineated as an enlarged thyroid gland with a component extending into the mediastinum, at least 10 definitions have described being able to depict the most accurate definition for substernal goiter. Of note, no consensus still has been declared on the therapeutic management of asymptomatic substernal goiter. It should be pointed out that, the American Association of Endocrine Surgeons (AAES), Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults reported approximately 9% to 13% of substernal goiters are being harbored thyroid malignancy. The following vignette case describes the clinical features of a symptomatic substernal goiter with chronic lymphocytic thyroiditis, her treatment by sutureless total thyroidectomy with intermittent-intraoperative neural monitoring (I-IONM), and the energy-based device without sternotomy, and the response of an adult who presented with a family history of malignant histopathology, differentiated thyroid carcinoma, which was exposed to the postoperative radioactive iodine ablation. We may recommend dividing the branches of superior thyroid arteries and the superior thyroid veins individually and exploring the fibrous Ligament of Berry, the true Ligament of Berry, with its safe interrelation to the inferior laryngeal nerve, finically, which may be regarded as different peas in a pod in a complete sutureless thyroidectomy for substernal goiter with thyroiditis in thyroidology.
Highlights
The term goiter refers to enlargement of the thyroid gland which is concealed with the thin muscles, subcutaneous fatty tissue, and delicate skin of the neck, those notwithstanding sufficiently while growing
A total thyroidectomy by the collar incision without a median sternotomy with intermittent-intraoperative neural monitoring (I-IONM) and the energybased device was decided in order of facing with symptomatic substernal goiter, including the bilateral multiple nodules, that did not extend beyond the left innominate vein proximally, such the vital organs like as the arcus aorta
Afterwards, the right side was dissected and spared in a similar fashion with the relevant exposures of the branches of right superior thyroid artery and right superior thyroid vein, right superior laryngeal nerve, right superior and inferior parathyroid glands, right inferior thyroid artery and vein, and right recurrent laryngeal nerve (RLN) by using LigaSure Small Jaw (LSJ) (LF1212A) and I-IONM. Both the RLNs, per se, were not lying over the enlarged gland as being possible in case of a substernal goiter. What follows both thyroid lobes with the isthmus and pyramidal lobe were resected with the aid of the I-IONM and energy-based device, the mini roll behind the posterior aspect of the neck was removed in order to attenuate the collar tension, the wound was profusely and meticulously irrigated with the sterile saline and the relevant haemostasis was provided
Summary
The term goiter refers to enlargement of the thyroid gland which is concealed with the thin muscles, subcutaneous fatty tissue, and delicate skin of the neck, those notwithstanding sufficiently while growing. Her personal medical history has included diabetes mellitus, hypertension, hyperlipidemia, atrial fibrillation, and familial mediterranean fever while her family history, her sister, who was comprising differentiated thyroid carcinoma, papillary thyroid carcinoma, underwent total thyroidectomy with a subsequent RAI ablation. Her vital signs were recorded within normal limits and she had no history of radiation exposure in the first two decades of her life. The neck magnetic resonance imaging (MRI) revealed a multinodular goiter with the largest nodule, 24 x 20 mm in diameter, in the left lobe inferior, expanding retrosternally while her thorax MRI put forward the left lobe was descending to the left brachiocephalic vein and the trachea was displaced to the right.
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