Cervical Goiter Research Articles

A rare clinical case of malignant ectopic retrosternal goiter of a large size in a patient with aberrant right subclavian artery

Background. Ectopic goiter accounts for only 0.2 % to 1 % of all mediastinal goiters. The aberrant right subclavian artery (arteria lusoria) is an extremely rare anomaly of the major vessel, with a prevalence not exceeding 0.3 % in the general population. This paper presents the first case of malignant ectopic retrosternal goiter of a large size in combination with the aberrant right subclavian artery. Clinical case description. A 61-year-old male presented to the thoracic surgery department of P. Herzen Moscow oncology Research institute with a large posterior mediastinal mass measuring 108×106×79 mm and adjacent to the right lobe of the thyroid gland. The tumor displaced the trachea and esophagus. Open biopsy through a thoracotomy incision revealed thyroid gland cells without signs of atypia. A detailed examination revealed mediastinal vascular anomaly – retrotracheal position of the right subclavian artery. a complete longitudinal sternotomy, complemented by a right-sided thoracotomy at the 3rd intercostal space, served as the surgical approach. The operation lasted 320 minutes, with a blood loss of 3500 ml. The postoperative period was uneventful. The morphological examination of the surgical specimen revealed nodular hyperplasia of the ectopic thyroid tissue with the growth of well-differentiated follicular carcinoma without metastatic involvement of removed lymph nodes. Considering the identified follicular carcinoma, total thyroidectomy was performed. Conclusion. In surgical planning, it is crucial to assess the location of major mediastinal vessels and their relationship with the goiter. Therefore, all patients with mediastinal lesions should undergo preoperative contrast-enhanced ct. Retrosternal goiter predisposes to a higher rate of malignancy compared to cervical goiter. If the lower edge of the goiter is at the level of or below the aortic arch, cervical access should be supplemented with sternotomy. In cases of a massive thoracic component, additional thoracotomy is justified.

Differences in surgical outcomes between cervical goiter and retrosternal goiter: an international, multicentric evaluation.

Goiter is a common problem in clinical practice, representing a large part of clinical evaluations for thyroid disease. It tends to grow slowly and progressively over several years, eventually occupying the thoracic inlet with its lower portion, defining the situation known as retrosternal goiter. Total thyroidectomy is a standardized procedure that represents the treatment of choice for all retrosternal goiters, but when is performed for such disease, a higher risk of postoperative morbidity is variously reported in the literature. The aims of our study were to compare the perioperative and postoperative outcomes in patients with cervical goiters and retrosternal goiters undergoing total thyroidectomy. In our retrospective, multicentric evaluation we included 4,467 patients, divided into two groups based on the presence of retrosternal goiter (group A) or the presence of a classical cervical goiter (group B). We found statistically significant differences in terms of transient hypoparathyroidism (19.9% in group A vs. 9.4% in group B, p < 0.001) and permanent hypoparathyroidism (3.3% in group A vs. 1.6% in group B, p = 0.035). We found no differences in terms of transient RNLI between group A and group B, while the occurrence of permanent RLNI was higher in group A compared to group B (1.4% in group A vs. 0.4% in group B, p = 0.037). Moreover, no differences in terms of unilateral RLNI were found, while bilateral RLNI rate was higher in group A compared to group B (1.1% in group A vs. 0.1% in group B, p = 0.015). Wound infection rate was higher in group A compared to group B (1.4% in group A vs. 0.2% in group B, p = 0.006). Based on our data, thyroid surgery for retrosternal goiter represents a challenging procedure even for highly experienced surgeons, with an increased rate of some classical thyroid surgery complications. Referral of these patients to a high-volume center is mandatory. Also, intraoperative nerve monitoring (IONM) usage in these patients is advisable.

Dual Ectopic Thyroid: A Case Report and Review of the Literature

Ectopic thyroid tissue is an uncommon anomaly, and the presence of dual ectopic thyroid tissues in a single patient is exceedingly rare. We describe a 69-year-old woman who presented with dyspeptic symptoms, asthenia, aphonia, and chronic fatigue. The patient was eventually found to have a multinodular goiter, cervical goiter, and mediastinal goiter. The patient underwent radical thyroidectomy and dissection, followed by treatment with levothyroxine. This report underscores the diagnostic challenges in complex presentations of ectopic thyroid tissue.

BREAST CARCINOMA WITH LOBULAR COMPONENT DISCOVERED BY THYROIDMETASTASIS: A CASE REPORT

Objective: Breast cancer is the most common cause of cancer-related deaths and is frequently diagnosed in women worldwide. The purpose of this study is to report a case of breast carcinoma with lobular component discovered through thyroid metastasis at the Mohammed VI University Hospital in Marrakech. Case presentation: The patient, a 59 year old multiparous postmenopausal woman with a history of diabetes and hypertension, was referred from the ENT department for a thyroid localization of a carcinomatous process of mammary origin, incidentally discovered during total thyroidectomy + lymph node dissection. A cervical mass had been evolving for approximately 2 years. Results: Physical examination revealed a cervical scar from thyroidectomy, along with an ulcerated lesion of the left breast measuring 2 x 2 cm in the sub-mammary groove, without palpable nodules or lymphadenopathy. Cervical CT scan showed a multinodular and heterogeneous cervical goiter, leading to the recommendation of total thyroidectomy + lymph node dissection. Histopathological examination with immunohistochemistry confirmed a thyroid localization of a mammary-origin carcinomatous process, specifically lobular type. Bilateral mammography revealed two lesions in the left upper outer quadrant and one near the left sub-mammary groove, associated with a left axillary lymph node classified as ACR 5. Biopsy of the sub-mammary lesion identified an infiltrating non-specific type of breast carcinoma with lobular differentiation, classified as luminal B. Following a multidisciplinary consultation, neoadjuvant chemotherapy AC60-Docetaxel + left patey post-chemotherapy was decided upon. Conclusion: Breast cancer metastases to the thyroid, as observed in this study, are rare. Only a few studies (39 cases) have reported this type of breast cancer metastasizing to the thyroid, highlighting the uniqueness of this studyin a southern country. Subject Areas: Gynecology &amp; Obstetrics.

ЭНДЕМИЧЕСКИЙ ЗОБ В РЕСПУБЛИКЕ САХА (ЯКУТИЯ)

The authors conducted a study of the prevalence and features of the course of endemic goiter in the Republic of Sakha (Yakutia). According to the classification, the area is considered endemic for goiter if a goiter-altered gland is observed in more than 10 % of the population. There are light, medium and severe goiter endemias. It was revealed that, on average, the prevalence of endemic goiter in the republic is 28 %, which corresponds to the average severity of endemia, but the level of endemia is heterogeneous: there are areas of Yakutia with a severe degree. The peculiarities of endemic goiter in the Republic of Sakha (Yakutia) should also include the predominance of euthyroid forms (92.8 %) and a high (up to 57.3 %) proportion of thyroid nodules in areas with severe endemia. An important feature is the significant frequency of histologically confirmed thyroid malignancies: 8.2 % of the number of operated. In addition to the lack of iodine and a number of other trace elements in the environment, the body as a whole and, in particular, the thyroid is affected by a number of specific features of Yakutia: extreme temperature and light conditions, pronounced seasonality of climate, anomalies of geomagnetic fields. The predominance of nodular formations of the thyroid gland in endemic areas, especially polynodose (up to 86.9 %), is one of the prerequisites for the more frequent development of cervical-thoracic goiter. Cervical-thoracic goiter requires surgical intervention due to manifestations of compression of the mediastinal organs or the threat of their development. Unlike cervical goiter, with cervical-thoracic goiter, there is a problem of differential diagnosis with other intra-thoracic formations.

Substernal Goiter: From Definitions to Treatment.

The enlargement of multinodular goiter into the mediastinum through the thoracic inlet or ectopic thyroid tissues directly in the mediastinum is defined as Substernal Goiter (SG). However, there is no clear consensus in the literature on this definition. There are many definitions for SG in the literature. Most definitions are similar or overlapping. Since the thyroid is located in the neck above the thoracic inlet in its normal anatomical position, the simplest clinical definition should be preferred among the definitions regarding its descent below the thoracic inlet and adjacent to the mediastinal organs. In the American Thyroid Association guideline, SG is defined as clinical or radiological protrusion of the thyroid gland over the sternal notch or clavicle in a patient with a slightly extended neck in the supine position. SGs can be classified as primary or secondary according to their origins. In addition, there are combined SGs resulting from the enlargement of the primary SG, which is the growth of the cervical thyroid gland toward the mediastinum, and the secondary SG, which is defined as an ectopic mediastinal mass, together. We find it appropriate to define such SGs as mixed SGs. In this disease, which has the same etiology and etiopathogenesis as cervical goiter, the descent of the thyroid gland into the mediastinum due to some anatomical factors explains the physiopathology. Compression symptoms of mediastinal major vascular structures, trachea, and esophagus cause the symptoms and findings of SGs due to its localization. In addition, the relationship of SGs with possible malignancy risk and hyperthyroidism affecting the indications and methods of treatment has been discussed for a long time. In this study, we aimed to evaluate the definitions, classification, physiopathology, laboratory and imaging methods used for diagnosis, the relationship of SG with hyperthyroidism and malignancy, and briefly the treatment methods, according to the current studies from literature.

Efficacy and safety of single-session radiofrequency ablation for intrathoracic goiter: preliminary results and short-term evaluation

Background An intrathoracic goiter (ITG) is defined as a thyroid extension below the sternal notch. Compared to cervical goiters, surgery for ITG is more challenging, with a higher risk of an extracervical approach. Ultrasound (US)-guided radiofrequency ablation (RFA) is a minimally invasive treatment modality. The purpose of this study was to prospectively evaluate the safety and efficacy of RFA in patients with ITG. Methods From a total of 324 patients who underwent thyroid RFA at a single medical center, 15 patients (mean age 52.2 years; 73.3% female) with 16 ITGs were included and classified into three grades and three types using the cross-section imaging CT system. Clinical features and demographics, degree of extension, RFA details, goiter volume, and complications were analyzed. Results Mean pre- and post-RFA goiter volumes as measured by US were 106.62 ± 61.82 and 25.09 ± 14.22 mL respectively, with a volume reduction rate (VRR) of 75.5% (p < 0.001) at 6 months. The VRR as measured by CT/MRI was 57.0 ± 10.0% (p < 0.001) at 6 months. The intrathoracic length reduction rate at 6 months was 44.9 ± 39.2% (p = 0.001). In addition, 4 (25%) ITGs had total regression of the intrathoracic extension, with a downgrade from grade 1 to cervical goiter. Mean pre- and post-RFA symptom and cosmetic scores were 1.53 and 0.15 (p = 0.001), and 2.67 and 2.00 (p = 0.001), respectively. One patient had transient vocal cord palsy and another had perithyroidal and mediastinal hemorrhage. Conclusion US-guided RFA is an effective treatment for ITG in terms of both cervical and intrathoracic reductions with an acceptable complication rate.

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.

Fatal Acute Upper Airway Obstruction Due to Cervical Goiter: A Rare Case Report

Fatal Acute Upper Airway Obstruction Due to Cervical Goiter: A Rare Case Report

Thyroidectomy in a patient with a giant multinodular nontoxic cervical retrosternal goiter

A clinical case of successful surgical treatment of a patient with a giant cervical retrosternal nontoxic goiter with severe cardiac pathology is presented. Thyroidectomy from cervical access without sternotomy was performed. At the follow-up examination 5 months after the operation, instrumental and clinical signs of disease relapse were not detected.

« Neglected » Endothoracic Goitres : The Point of View of Thoracic Surgeon

Introduction : Neglected endothoracic goiter is an endothoracic mediastinal portion that was neglected during the surgical removal of a plunging cervical goiter in contrast to autonomous ectopic mediastinal goiter which has its own mediastinal vascularization without connection between the two components and but who was not diagnosed during the cervical thyroidectomy. The aim of this work is to report the point of view of thoracic surgeon to avoid "forgetting" this endothoracic component.Materiel and methods : This is a retrospective study involving four patients, all operated for an endothoracic goiter only by thoracotomy.Results : Among four patients, it was 3 women and one men with an average age of 46 years. All Four cases have already been operated for cervical goiter by cervicotomy alone. Also, for all patients, the discovery was accidental. the cervicothoracic scan found a posterior mediastinal heterogeneous mass, with calcification lesions in 2 patients, and necrosis zone in 2 patients. The four patients were operated by posterolateral thoracotomy. Operative outcome was simple in all patients except 2 cases of wound infection.Conclusion : Neglected endothoracic goiter poses a diagnostic and also a therapeutic problem because its a difficult surgery due to the adhesions already formed following a first cervical thyroid surgery and therefore it is essential not to miss the diagnosis of any diving goiter.

ACUTE AIRWAY OBSTRUCTION DUE TO CERVICAL GOITER IN A POST-OPERATIVE PATIENT

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Benign cervical goiter, though very common, is a rare cause of upper airway obstruction. In most cases there is a significant retrosternal extension of the goiter that leads to chronic respiratory failure. Here we present a case of upper airway obstruction due to a cervical goiter causing acute respiratory failure in a post-operative patient. CASE PRESENTATION: A 67-year-old woman with a past medical history of diabetes, hypertension, coronary artery disease and hypothyroidism presented to our facility with palpitations and shortness of breath. She underwent extensive evaluation including cardiac catheterization, which showed triple vessel disease. She was subsequently referred for coronary artery bypass grafting. On the second postoperative day, the patient developed sudden onset of shortness of breath and complained of feeling like her throat was closing. She was intubated for acute respiratory failure and placed on mechanical ventilation. Extubation was attempted twice in the post-operative period, but on both occasions, she relapsed into hypercarbic respiratory failure shortly after withdrawal of the endotracheal tube. After a prolonged period of intubation, she was referred for tracheostomy. She eventually required a subtotal thyroid resection before the trachea could be accessed. She was discharged with the tracheostomy in place DISCUSSION: Our patient had multiple comorbid conditions, underwent a major surgical procedure and received analgesic medications with sedative properties. These elements taxed her physiological reserve. She was therefore unable to maintain the same respiratory effort and could no longer overcome the resistance caused by airway narrowing due to the goiter. After prolonged intubation and failed attempts at extubation, tracheostomy was felt necessary. Benign goiters are very common, but do not often lead to upper airway obstruction. However, in critically ill or in post-operative patients, they can have significant influence on the prognosis. The presence of a large cervical goiter should be viewed as a risk factor for upper airway obstruction during the post-operative period. CONCLUSIONS: Acute respiratory failure due to benign cervical goiter is uncommon. However, in post-operative or critically ill patients, it should be factored as a potential cause of respiratory failure and considered during the pre-operative assessment. Reference #1: Bayhan Z, Zeren S, Ucar BI, et al. Emergency thyroidectomy: Due to acute respiratory failure. Int J Surg Case Rep. 2014;5(12):1251-3. Reference #2: White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg. 2008;32(7):1285-300. Reference #3: Ito T, Shingu K, Maeda C, et al. Acute airway obstruction due to benign asymptomatic nodular goiter in the cervical region: A case report. Oncol Lett. 2015;10(3):1453-1455. DISCLOSURES: No relevant relationships by Israel Acosta Sanchez, source=Web Response no disclosure on file for Ali Ashraf; No relevant relationships by Anthony Chahin, source=Web Response No relevant relationships by Jovan Gayle, source=Web Response No relevant relationships by Relin Yang, source=Web Response

Factors influencing extent of surgery for Substernal Thyroid Goiters: Hemithyroidectomy versus total Thyroidectomy

Background: When compared to removal of cervical goiters, patients undergoing removal of substernal goiter have been found to have higher rates of complications, including recurrent laryngeal nerve injury, bleeding, and hypoparathyroidism. Previous literature has discussed hemithyroidectomy versus total thyroidectomy for cervical goiters showing that the less invasive procedure was a reasonable option with decreased morbidity overall.

Surgical approach to the intrathoracic goiter.

ObjectiveIn a retrospective study, the authors analyzed the surgical approach to the intrathoracic goiter to avoid sternotomy or thoracotomy.MethodsWe selected 70 intrathoracic cases of multinodular goiter out of 988 cases of thyroidectomy and compared them with cervical goiter cases. Surgical technique, results, and postsurgical complications were assessed.ResultsThe analyzed cases presented the retrosternal goiter (n = 53; 75.7%), the retrotracheal goiter (n = 9; 12.8%), and the retroesophageal goiter (n = 8; 11.4%). Complaining of chest pressure or discomfort was specific for intrathoracic cases (50%; 35 of 70). All goiters except one were removed via cervical incision. The surgeons used head reclination and isthmus dissection when removing sizable goiters. Mean weight of goiters was 180 g. The recurrent laryngeal nerve was more often temporarily damaged in intrathoracic cases in comparison with cervical cases (4.3% vs. 2.8%, P = .04), but the difference in permanent injury was less significant (P = .09). The incidence of temporary hypoparathyroidism was significantly higher in intrathoracic cases (P = .01).ConclusionIn cases of multinodular goiter the goiters of various extensions can be successfully removed via the cervical incision in most of the cases even if they occupy the retrosternal, retrotracheal, or retroesophageal position. The transthoracic approaches and sternotomy might be justified in malignant cases.Level of Evidence4.

Substernal goiter and laryngopharyngeal reflux.

This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

Preoperative risk factors in total thyroidectomy of substernal goiter.

The definition of substernal goiter (SG) is based on variable criteria leading to a considerable variation 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. The aim of this study was 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 retrovascular 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. All but two procedures were terminated via cervicotomy, where partial sternotomies were required. No perioperative mortality was observed. Results of the statistical analysis (Student’s t-test and Fisher’s 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=0.0124, 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=0.0696, and need to treat =20.8) compared to the group that underwent TT of cervical goiter. TT is the procedure to perform in SG even if the incidence of complications is higher than for cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina. In the presence of these factors, greater care should be taken.

Anatomical approach to surgery for intrathoracic goiter.

The anatomical approach to the intrathoracic goiter (ITG) was used to understand its etiology and to rationalize surgical technique of thyroidectomy. For a retrospective chart review, we selected cases of multinodular goiter with totally ITGs (n=69; M 29, F 40), while 916 cases with cervical goiter were used for comparison. The topography of the thyroid gland was assessed against the tracheal rings and against the vertebrae. The regional anatomy of the thoracic inlet was assessed by its bony margins and the relations of structures traversing the area. Average tracheal-diameter-to-thoracic-inlet ratio was calculated. The ITG group consisted of 52 cases of retrosternal goiter (75.4%), nine cases of retrotracheal goiter (13%), and eight cases of retroesophageal goiter (11.6%). In all but one analyzed cases, the goiters were removed via cervical incision. Mean weight of goiters was 183g. The area of thoracic inlet in the cases of ITG had no difference in comparison with the cases of cervical goiter (F/M p=0.11/0.15), but the tracheal-diameter-to-thoracic-inlet ratio was significantly smaller (F/M p=0.06/0.04). In the ITG cases, the position of the upper edge of the isthmus of the thyroid was about 1.5 tracheal rings lower than in healthy individuals (p=0.03). The area of the thoracic inlet, the neck size, and the anteroposterior diameter of the inlet do not affect the development of the ITG. The smaller tracheal-diameter-to-thoracic-inlet ratio and the lower position of the thyroid gland are the main indicators for the development of the ITG.

Acute airway obstruction due to benign asymptomatic nodular goiter in the cervical region: A case report

Benign nodular goiter is a common disease. Although large goiters with obstructive symptoms including shortness of breath and dyspnea are a clear indication for surgery, acute upper airway obstruction, particularly in benign cervical goiter cases, is rare. We herein report the case of 46-year-old female with acute upper airway obstruction due to benign nodular goiter. The patient had a large and elastic goiter which was more pronounced on the left side of her neck, and surgery was scheduled for within a few months. Three months after the initial presentation, while still waiting for surgery, the patient was brought to the emergency room due to loss of consciousness and breathing difficulty and was immediately intubated. A computed tomography (CT) scan revealed that the trachea was markedly compressed by a nodular lesion in the left lobe, and bilateral pneumonia was also evident. Total thyroidectomy was immediately performed via the supraclavicular approach. The patient had an uneventful postoperative course and recovered well. The resected specimen included a well-encapsulated solid and cystic mass. Histopathological examination mainly revealed adenomatous goiter. The present case suggests that benign asymptomatic nodular goiter mostly located in the neck may cause acute airway obstruction, even if the nodules are not large. Early surgery should be performed when tracheal deviation and stenosis due to a large goiter is prominent by CT scan.

Substernal goiter: when is a sternotomy required?

BackgroundSternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach to thyroidectomy. We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG and analyzed the preoperative and postoperative characteristics of patients with SSG compared with those with large goiters contained entirely within the neck or a cervical goiter. MethodsA retrospective review of a surgical database was performed. We included patients with large (>100 g) thyroids or SSG, regardless of size. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had an SSG and patients who had a cervical goiter with particular focus on those who required sternotomy. ResultsOf the 220 patients, 127 patients (58%) had SSG, of whom 7 (5.5%) required sternotomy. All patients who underwent sternotomy underwent preoperative computed tomography scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints and have extension of the thyroid gland below the aortic arch. Sternotomy took an average of 2 hours longer than a cervical incision, was associated with significantly more blood loss (600 versus 190 mL, P = 0.04), and a longer length of stay (3.1 versus 1.8 d, P = 0.03) than cervical thyroidectomy. ConclusionsSternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch and were more likely to present complaining of chest pressure and voice issues.

Recurrent laryngeal nerve palsy and substernal goiter. An Italian multicenter study

The aim of this retrospective multicenter study was to verify whether the substernal goiter and the type of surgical access could be risk factors for recurrent laryngeal nerve palsy during total thyroidectomy. Between 1999-2008, 14,993 patients underwent total thyroidectomy. Patients were divided into three groups: group A (control; n=14.200, 94.7%), cervical goiters treated through collar incision; group B (n=743, 5.0%) substernal goiters treated by cervical approach; group C (n=50, 0.3%) in which a manubriotomy was performed. Transient and permanent unilateral palsy occurred significantly more frequently in B+C vs. A (P≤.001) and in B vs. A (P≤.001). Transient bilateral palsy was significantly more frequent in B+C vs. A (P≤.043) and in C vs. A (P≤.016). Permanent bilateral palsy was significantly more frequent in B+C vs. A (P≤.041), and in B vs. A (P≤.037). Extension of the goiter into the mediastinum was associated to increased risk of recurrent nerve palsy during total thyroidectomy.