Huge Goiter Research Articles

Airway management of huge thyroid swelling having tracheal deviation: Challenges faced

Airway management in huge goiters present with challenges among anesthesiologists worldwide. Usually thyroid swelling presents with retrosternal extension, tracheal compression poses certain airway challenges. In our case there was no retrosternal extension or tracheal compression but tracheal deviation was present which make airway management difficult.55yr old male pt, weight 60 kg, moderately built, came with chief complaints of gradually increasing swelling in front of neck since 3 years. He was k/c/o systemic hypertension on regular treatment taking tab. amlodipine 5mg OD. He was having no change in voice, no other systemic illness. He was evaluated for left sided huge goitre having neck swelling of size 14 cm × 15 cm × 10 cm. The mass was extending from lower jaw to below sternal notch, get below the swelling was possible. Xray neck AP and lateral view revealed tracheal deviation to right by the mass, this patient was posted for the hemithyroidectomy considering difficult airway plan of anaesthesia was awake fibreoptic intubation (under topical anaesthesia and sedation). In this case because of tracheal deviation to right the glottic structures were distorted, view to vocal cords was obscured by left arytenoid making the airway management difficult.In general the difficulty of tracheal intubation in cases with thyroid disease is affected by compression or deviation of the trachea, the position and hardness of the tumour. Generally recommended techniques for securing airway in such patients are 1. Awake fiberoptic intubation 2. Awake direct laryngoscopy aided intubation 3. Inhalational induction. Awake fibreoptic intubation using local anaesthesia - sedation technique is a suitable option in selected group of patients having possibility of airway obstruction.

Goiter in a fresco by i Fiammenghini, 1615 (Abbey of Santa Maria di Rovegnano, Chiaravalle, Italy).

In a large fresco, which narrates brutal episodes of torture against Cirtercian monks, in the right corner of the background an ugly aggressor with a huge goiter, symbol of evil and sin, attacks a monk with a sword.

Sutureless Total Thyroidectomy for Substernal Goiter: Amending Versus Unnecessary.

Substernal goiter is an enlarged thyroid gland, harboring a component extending into the mediastinum. Surgical management requires genuine and rigorous preoperative planning as physicians could encounter the prospect of the gland coming into close quarters with the vital intrathoracic structures. The neck and chest multiplanar cross-sectional imaging provide essentialness of an extracervical approach for the procedure. In the present study, a 57-year-old female who admitted with the intermittent dyspnea and dysphagia with a huge goiter is reported. The labs were reported within the normal limits and the video laryngoscopy displayed no pathologic finding. Her neck sonography revealed the multiple nodules within the gland, without determining the most proximal border of the left lobe. The neck and chest computed tomography depicted a substernal goiter harboring the left lobe, extending till the left innominate vein and a sutureless total thyroidectomy by the collar incision without a median sternotomy was performed. We would recommend sutureless thyroidectomy for substernal goiter just considering to divide meticulously the superior thyroid arteries and veins separately and exploring the fibrous Ligament of Berry, that is, the true Ligament of Berry, with its safe relationship to the recurrent laryngeal nerve in Thyroidology.

NOVEL TECHNIQUES FOR DIFFICULT AIRWAY MANAGEMENT IN VARIOUS CLINICAL SCENARIOS: CASE SERIES AND REVIEW OF LITERATURE

Difficult airway management has till date been the most fearsome and challenging part of any anaesthetic management. Meticulous planning is always done prior to anaesthetic induction of such patients with multiple back up plans and rescue strategy. Significant advancements in terms of clinical protocols, techniques, and devices / gadgets in this field have led to decreased incidence of airway related complications. We hereby present a case series of 3 clinical cases with different airway scenarios; 1) Patient with huge goiter, who was intubated with the help of an indigenously developed fish mouth valve device, 2) a temporomandibular joint ankylosis case, managed with awake fibreoptic guided intubation 3) Patient with post burn contracture of face and neck, in which fibreoptic intubation was performed after partial release of scar under tumescent anaesthesia. Extensive preoperative airway evaluation and preparation to handle any emergency by multiple backup plans always helps in smooth sailing through these difficult clinical scenarios

Extracorporeal membrane oxygenation for surgery to remove a huge goiter causing tracheal obstruction

Extracorporeal membrane oxygenation for surgery to remove a huge goiter causing tracheal obstruction

Will the shepherd be able to play the alpine horn with that huge goiter (XVI century)?

There are many of the representations in iconography of individuals with goiters reported in the literature. The article describe a unique representation of goiter, as observed by the authors in a sculpture in Italy. In a Nativity, in the upper part of the altar of the Church of the Annunciata, Boccioleto (Val Sermenza, Piedmont, Italy), a horn player with a huge goiter, gladdens the Holy Family. Wooden work by Francesco Antonio d'Alberto, 1694. This is an appropriate example of the iconography of "real goiter," since in this case the sculptor had the aim of showing person with goiter.

Multidisciplinary Management of Intrathoracic Goiter: A Case Report

Introduction: Intrathoracic goiters are associated with compression of nearby structures, triggering severe compressive symptoms. Total thyroidectomy is the gold standard to treat these cases. Case Presentation: A patient with a huge intrathoracic goiter suffering from compressive symptoms underwent a thorough clinical, functional and imaging assessment and underwent total thyroidectomy in an Endocrino-Metabolic surgical referral center; after the surgery she suffered from transient hypocalcaemia but was discharged without major complications and continued periodical endocrinological follow-up. Conclusion: Management of intra-thoracic goiter requires a multidisciplinary approach of a skilled team both pre, during and after surgery to maximize the safety and efficacy of the procedure and reduce or promptly manage surgical or medical complications.

Challenges for huge goiter surgery

Objective To highlight the technical challenges and perioperative management of huge goiter guided by ultrasound scanning and, in some cases, computed tomography (CT) scan. Patients and methods Twenty-seven patients presented with large thyroid masses, whether primary or recurrent, and were studied and investigated retrospectively. Triple assessment was done for all patients in the form of history and physical examination, imaging studies, and fine-needle aspiration cytology. Intraoperative technical challenges and postoperative complications were focused on. Every patient has been scanned primarily by ultrasound examination of the neck followed by CT scan if ultrasound was unable to answer all the questions asked and requested by the treating physicians. Results All patients underwent surgical intervention in the form of total or completion total thyroidectomy with or without central lymph node dissection. Transient hypocalcemia was seen in six (22.22%) patients. (Three 11.11 %) patients developed postoperative temporary hoarseness of voice. No major intraoperative or postoperative bleeding was encountered, and no evidence of recurrence was detected during the follow-up period from 6 months to 3 years. Ultrasound was considered enough imaging modality in seven out of the 27 patients, whereas CT scan had to be done in the remaining 20 patients. Conclusion Thyroidectomy for huge goiter is a technical challenge but remains the best option for effective and definitive management. Diagnostic radiology is considered an essential part in the preoperative assessment of these patients. Comprehensive perioperative management and team work are crucial for successful outcomes.

Struma kao prediktor otežane intubacije - prikaz slučaja

Introduction: Preoperative examination and recognizing the risk factors for a difficult airway gives us the time for optimal preparation for difficult airway management. For goiter patients, in addition to the standard risk factors, there are goiter-related factors that may address to suspect of difficult intubation. Case report: Through this case report we summarize the presentation, airway examination and management of a patient with huge goiter. About 25-years earlier he noticed a swelling on the neck which increased in size progressively. Over the years he developed compressive symptoms, such as dysphagia, hoarseness and change in voice quality. All classical risk factors for difficult intubation, as well as goiter-related factors, were preoperatively evaluated. The neck circumference, the left displacement of the larynx and the radiological findings all pointed to a possible difficulty in airway management. The plan was to perform a direct laryngoscopy using a video-laryngoscope, without using a muscle relaxant, whereas the alternate plan was to use a flexible fibreoptic bronchoscope. The patient's airway was anesthetized with lignocaine spray into the laryngo-pharynx 30 minutes and 10 minutes before intubation. Oxygen was administered via facemask. The nasal catheter was placed to provide apnoic oxygenation during laryngoscopy and intubation. After induction of anesthesia a smooth video laryngoscopy was performed without using a muscle relaxant. A reinforced endotracheal tube with an intubating stylet was inserted without any difficulties in passing and placing the tube. Conclusion: Careful planning and detailed preoperative preparation are of crucial importance for a safe intraoperative and postoperative outcome in thyroid patients.

Suturing of tracheomalatic rings complicating long-standing huge goiters to adjacent structures

Five patients selected having huge goiter compressing and deviating trachea, with criteria of tracheomalacia which were scheduled for total thyroidectomy with fixing tracheomalatic rings to adjacent structures instead of other methods used previously, with follow-up more than 1 year. We report five cases of tracheomalacia following total thyroidectomy for huge multinodular goiters which were diagnosed and managed, despite different support techniques. The surgical management of tracheomalacia is still a challenging problem. It is found that this method is superior to other methods of overcoming tracheomalacia complicating huge goiter and associated with no/nor mortality, so this simple procedure can be used as a first line of treatment of tracheomalacia complicating long-standing huge goiter.

A marked goiter involved in Marine-Lenhart syndrome.

Marine-Lenhart syndrome is rare disease defined as coexistence of Graves' disease and autonomously functioning thyroid nodule. We will introduce a case of Marine-Lenhart with a huge goiter.

Successful airway management with combined use of McGrath® MAC video laryngoscope and fiberoptic bronchoscope in a severe obese patient with huge goiter -a case report.

Huge goitor can lead to tracheal compression and hence difficulty in intubation. This is compounded by severe obesity. Failed tracheal intubation in difficult intubation is a serious event that may lead to increased patient morbidity and mortality. Current intubation rescue techniques and combination of different rescue techniques may increase the success rate of difficult intubation. In a 47-year-old female patient, with severe obesity and a huge goiter, our attempts at intubation using direct laryngoscope, video laryngoscope, and awake fiberoptic bronchoscope had failed. We succeeded by applying video laryngoscope to improve visualization of the airway and fiberoptic bronchoscope as a stylet for endotracheal tube.

A Review of Methods for the Preservation of Laryngeal Nerves During Thyroidectomy.

The recurrent laryngeal nerve (RLN) provides motor innervation to the abductor and adductor muscles of the vocal cord, whereas the external branch of the superior laryngeal nerve (EBSLN) provides motor innervation to the cricothyroid muscle, which is the tensor muscle of the vocal cord. Both the RLN and the EBSLN are anatomically close to the thyroid and are therefore at risk of injury during thyroidectomy. These 2 laryngeal nerves must be carefully preserved during surgery to ensure that the function of the vocal cord is not impaired. Currently, complete exposure of the RLN during thyroidectomy is accepted as the gold standard method for the preservation of RLN. Sufficient knowledge of surgical anatomy, clinical experience, and meticulous surgical techniques are key factors in the identification and safe dissection of the RLN. During a thyroidectomy, the RLN can be identified using four different approaches, depending on the type of thyroid growth and choice of the surgeon: There are lateral, inferior, superior, and medial approaches.The lateral approach is the most commonly used technique in primary thyroid surgery. The RLN is usually found by dissection around the inferior thyroid artery at the level of the middle lobe of the thyroid. RLN is generally found at the site of its entry into the neck region devoid of scar formation when the inferior approach is used especially in cases with secondary surgery. The superior approach is recommended for patients with an huge goiter or large substernal goiter. In this approach, the upper pole of the thyroid is first released and then pulled forward and laterally, and the RLN is exposed on the nerve’s entry point (NEP), into the larynx, under the cricopharyngeus muscle. The medial approach is preferred for patients with substernally or retropharyngeally enlarged goiters. In this approach, the isthmus is first dissected and divided, and then the isthmus and the medial part of the lobe are dissected away from the trachea to reveal the anterolateral part of the trachea. The fibers between the lateral aspect of the second or third tracheal rings and the thyroid, and the fibers of the Berry ligament are gradually dissected cranially, to allow RLN to enter into the field of view lateral to the trachea. The preservation of the anatomical integrity of the RLN does not indicate that its functional integrity is also preserved. IONM is a tool for the functional assessment of RLN, and so this method is an addition to visually identifying RLN, which is the gold standard. IONM significantly contributes to visual identification of the RLN, determination of its anatomical variations, intraoperative recognition of RLN injury, prevention of bilateral vocal cord paralysis, and detection and preservation of electrical activity in the nerve in patients with preoperative vocal cord paralysis.Although there is no standardized method for the preservation of the EBSLN, 3 methods have been defined during the release of the upper pole of the thyroid. These methods involve dividing the branches of the superior thyroidal artery one by one on the capsule without visually identifying the EBSLN, searching and visually identifying the EBSLN before the dissection of the upper pole vessels, or detecting the EBSLN and dissecting the upper pole under the guidance of IONM. IONM also significantly contributes to the detection and confirmation of the EBSLN and dissection and preservation of the upper pole of the thyroid gland.

Anterior Mediastinal Goiter Removed via Median Sternotomy: Short Communication and Literature Review

The majority of substernal goiters can be retrieved through the neck. However, sternotomy is indicated in roughly 1% to 8% of cases. Herein, we report a case of huge anterior mediastinal goiter...

A Rare Case of Huge Retrosternal Goitre Managed by Total Thyroidectomy with Medial Sternotomy

Retrosternal goitre is very rare condition which account for 5 to 20 % of thyroidectomy patients. Though rare, it can be better managed surgically. In this article we report a rare case of 60 year old female who had nodular goiter with huge retrosternal extension. Majority of retrosternal thyroid can be removed safely by conventional cervical approach. Our patient had around 20 x 18 x 6 cm mass which was impossible to remove it from conventional approach and hence total thyroidectomy with medial sternotomy was done. Procedure was uneventful and patient is doing fine in of follow-up. The role of thyroidectomy in patients with retrosternal goitre provides yet another area of surgical controversy I. Introduction Retrosternal goiter is defined when 50 % of the thyroid is below the thoracic inlet. This can also be called as intrathoracic goiter. Retrosternal goiter is a very rare condition which account for 5 to 20 % of thyroidectomy patients. Mediastinal extension is more common in huge goiters with a peak incidence in 5th to 6th decade. This is usually rare when the patient has associated hyperthyroidism which may increase the risk of complications. The reported incidence of goiters with thyroid malignancy is around 3 to 17 %. Retrosternal goitre occurs when the thyroid enlarges downwards into the chest. Although the great majority of retrosternal goitres are extensions from the neck, pure intrathoracic goitres are very rare. Any goitre that descends below the plane of thoracic inlet and growing into the anterior mediastinum for > 2cms.

Tracheal stenosis due to huge adenomatous goiter

Tracheal stenosis due to huge adenomatous goiter

Airway challenges in thyroid surgery

Huge goiters can lead to tracheal compression and, hence, difficulty in endotracheal intubation. This along with retro-sternal extension makes it an anticipated difficult airway scenario. In this report, we present a case of huge goiter (papillary carcinoma) compromising the airway, which presented with difficult airway for total thyroidectomy. CT scan of neck revealed retro-sternal extension with the pretracheal plane fixed to the trachea. Trachea was completely pushed to the right. We successfully performed an awake direct laryngoscopy and successful intubation by locally anesthetizing the airway. Plan B was ready with fiberoptic bronchoscopy and rigid bronchoscopy. Patient was successfully extubated in the intensive care unit (ICU).

Report of a case of papillary thyroid carcinoma in association with Hashimoto's thyroiditis.

Hashimoto thyroiditis (HT) is an autoimmune disease, known to be the most common cause of hypothyroidism in nonendemic goitrous areas. It is usually characterized by symmetric, painless, and diffused but sometimes localized swelling of the thyroid gland with features of hypothyroidism. Papillary thyroid carcinoma (PTC), on the other hand, is the most common yet less aggressive form of thyroid cancer, especially in iodine-deficient areas. The coexistence of the two diseases is possible but not common. This case study reports a 50-year-old female with a 10-year history of a huge goiter, which was essentially symptom-free until about 3 months prior to presentation when the patient started complaining of neck pain, dysphagia, productive cough, and cold intolerance. Physical examination revealed focal cystic and tender area in the multinodular swelling and associated cervical lymphadenopathy on the left side of the neck. The serum thyroid stimulating hormone was high, sub-normal T3, and the T4 was low. The fine needle aspiration cytology yielded 10 ml of aspirate of pus admixed with altered blood which on microscopy showed a few suspicious follicular epithelial cells with open nuclei admixed with mainly neutrophil polymorphs, siderophages, and foam cells in a hemorrhagic background. The patient had an incision biopsy that showed areas displaying PTC and HT.

English

ABSTRACT: The conventional technique of thyroidectomy normally requires a long skin incision and wide skin flaps on the anterior neck. The target of Minimal invasive surgery is to achieve the same results as those obtained with traditional surgery, less trauma, better postoperative course and improved cosmetic results. The aim of this Prospective Cohort study is to compare Small Incision (3.5-4cm) Thyroidectomy with conventional large incision Thyroidectomy with respect to post-op complications & Cosmesis. Most of the patients were in the age group 30-50yrs. There was no statistically significant difference between the two groups with respect to complications, which were Hematoma (6%), Seroma (25%), Hypocalcemia (52.5%)[Transient (37%), Permanent (15%)], Recurrent Laryngeal Nerve Involvement (33%) [Complete (6%)]. The scar in Small Incision surgery was cosmetically far better compared to the large incision Surgery & this difference was statistically significant. This technique not recommended in huge goiter, Retro-sternal goiter, thryroiditis and malignant thyroid. We believe that MINET can be an alternative to the classic approach in selected cases, but cannot be recommended as a standard therapy. Study on a large number of patients and longer follow up periods is recommended.

Clinical concepts on thyroid emergencies.

Objective: Thyroid-related emergencies are caused by overt dysfunction of the gland which are so severe that require admission to intensive care units (ICU) frequently. Nonetheless, in the ICU setting, it is crucial to differentiate patients with non-thyroidal illness and alterations in thyroid function tests from those with intrinsic thyroid disease. This review presents and discusses the main etiopathogenetical and clinical aspects of hypothyroid coma (HC) and thyrotoxic storm (TS), including therapeutic strategy flow-charts. Furthermore, a special chapter is dedicated to the approach to massive goiter, which represents a surgical thyroid emergency.Data Source: We searched the electronic MEDLINE database on September 2013.Data Selection and Data Extraction: Reviews, original articles, and case reports on “myxedematous coma,” “HC,” “thyroid storm,” “TS,” “massive goiter,” “huge goiter,” “prevalence,” “etiology,” “diagnosis,” “therapy,” and “prognosis” were selected.Data Synthesis and Conclusion: Severe excess or defect of thyroid hormone is rare conditions, which jeopardize the life of patients in most cases. Both HC and TS are triggered by precipitating factors, which occur in patients with severe hypothyroidism or thyrotoxicosis, respectively. The pillars of HC therapy are high-dose l-thyroxine and/or tri-iodothyroinine; i.v. glucocorticoids; treatment of hydro-electrolyte imbalance (mainly, hyponatraemia); treatment of hypothermia; often, endotracheal intubation and assisted mechanic ventilation are needed. Therapy of TS is based on beta-blockers, thyrostatics, and i.v. glucocorticoids; eventually, high-dose of iodide compounds or lithium carbonate may be of benefit. Surgery represents the gold standard treatment in patients with euthyroid massive nodular goiter, although new techniques – e.g., percutaneous laser ablation – are helpful in subjects at high surgical risk or refusing operation.