Huge Goiter Research Articles

Predictive factors for intraoperative excessive bleeding in Graves’ disease

In Graves' disease, because a thyroid tends to have extreme vascularity, the amount of intraoperative blood loss (AIOBL) becomes significant in some cases. We sought to elucidate the predictive factors of the AIOBL. A total of 197 patients underwent thyroidectomy for Graves' disease between 2002 and 2012. We evaluated clinical factors that would be potentially related to AIOBL retrospectively. The median period between disease onset and surgery was 16 months (range: 1-480 months). Conventional surgery was performed in 125 patients, whereas video-assisted surgery was performed in 72 patients. Subtotal and near-total/total thyroidectomies were performed in 137 patients and 60 patients, respectively. The median weight of the thyroid was 45 g (range: 7.3-480.0 g). Univariate analysis revealed that the strongest correlation of AIOBL was noted with the weight of thyroid (p < 0.001). Additionally, AIOBL was correlated positively with the period between disease onset and surgery (p < 0.001) and negatively with preoperative free T4 (p < 0.01). Multivariate analysis showed that only the weight of the thyroid was independently correlated with AIOBL (p < 0.001). Four patients (2.0%) needed blood transfusion, including two requiring autotransfusion, whose thyroids were all weighing in excess of 200 g. The amount of drainage during the initial 6 hours and days until drain removal was correlated positively with AIOBL (p < 0.001, each). Occurrences of postoperative complications, such as recurrent laryngeal nerve palsy or hypoparathyroidism, and postoperative hospital stay were not correlated with AIOBL. A huge goiter presented as a predictive factor for excessive bleeding during surgery for Graves' disease, and preparation for blood transfusion should be considered in cases where thyroids weigh more than 200 g.

Multidisciplinary Management of Airway Obstruction and Superior Vena Cava Obstruction Secondary to Huge Retrosternal Goiter

Airway obstruction and superior vena cava syndrome (SVC) secondary to huge retrosternal goiter are medical emergencies which need meticulous attention to prevent potentially life threatening events. We reported a case of huge retrosternal goiter which was neglected for years and later complicated by obstruction to airway and superior vena cava. Team effort which mainly involved endocrine surgeon, cardiothoracic surgeon and anaesthetist had successfully removed the gland without significa t morbidity. He was on tracheostomy due to tracheomalacia and was managed by ENT surgeon. He was discharged well after 2 weeks.

Recurrent laryngeal nerve palsy during surgery for benign thyroid diseases: Risk factors and outcome analysis

We investigated the risk factors for postoperative recurrent laryngeal nerve (RLN) palsy and related outcomes in patients with benign thyroid diseases. From 2008 to 2010, 844 thyroidectomies for benign thyroid diseases (benign nodules in 447; Graves' disease in 377; huge goiter attributable to Hashimoto thyroiditis in 20) were performed at Noguchi Thyroid Clinic and Hospital Foundation. The otolaryngologists screened all patients for the presence or absence of RLN palsy by laryngoscope, both pre- and postoperatively. When RLN palsy was present, the patients were checked periodically by laryngoscopy without additional drug therapy until the recovery of vocal cord palsy or loss of contact. A total of 1,374 nerves were at risk during the thyroid surgery (bilateral risk in 530, unilateral risk in 314). No patient exhibited a bilateral RLN palsy. Unilateral postoperative RLN palsies were found in 45 patients (benign nodules in 25, Graves' disease in 19, and Hashimoto thyroiditis in 1). The RLN was involuntarily amputated in five patients during the operation. The incidence of RLN palsy was 5.3% per patient and 3.3% per nerve. The incidence of RLN palsy was greater in patients who underwent complete unilateral thyroid lobe resection compared with partial resection of the lobe (P = .04). The occurrence of RLN palsy was associated with the need for reoperation caused by postoperative bleeding and the reduced weight of the thyroid remnant in Graves' disease (P = .04 and P = .03, respectively). Among 40 patients with RLN palsy and excluding 5 amputated patients, the RLN palsy resolved in 34 patients (85%) within 12 months after the procedure. The remaining 6 patients (15%) were considered to have permanent RLN palsies. Complete resection of the thyroid lobe and reoperation for postoperative bleeding are the risk factors for postoperative RLN palsy in patients with benign thyroid nodules. In Graves' disease, smaller weight of the residual thyroid tissue contributes to the occurrence of RLN palsy. Most RLN palsies that do not require amputation of the nerve resolve spontaneously within 12 months after surgery. In this study, the palsy remained in 1.3% (11/844) of patients.

Obliteration of thyroid arteries as a new method of treatment of thyroid diseases

Standard methods including pharmacotherapy, radioiodine and surgery cannot always be applied in treatment of thyroid diseases. The limitations of these methods are: drug intolerance and their side effects, too low radioiodine uptake, high risk of surgery. The obliteration of thyroid arteries seems to be an alternative method which could be used in the stiuation of ineffective standard treatment. It is based on shut down of blood flow in chosen thyroid arteries by injection of embolizative material (histoacryl or particles of polyvinylic alcohol) into the vessels. The consequence of acute ischemia is a septic necrosis of the glandular tissue in a field being supplied by this particular artery. Further repair processes and fibrosis lead to the reduction of an active thyroid hormone synthesis and decrease of thyroid volume. Effects of the embolization on apoptosis induction and modulation of autoimmune reactions are also observed. Preoperative selective embolization of a huge goiter or thyroid cancer improves surgery outcomes, reduces the risk of haemorrhage and damage to surrounding tissue. Palliative use of embolization in advanced stages of thyroid cancer reduces symptoms and improves quality of life. Little invasive nature of this procedure in comparison to surgery, the lack of serious undesirable coincidence makes the embolization of thyroid arteries an attractive form of therapy, which may become a therapeutic option in many difficult clinical situations and may improve the effectiveness of treatment of thyroid disease. The authors present the experiences gained in their institution with conclusions as follows: 1. As a result of using embolization of thyroid arteries in the treatment of selected thyroid diseases the following observations have been made: a significant reduction in goiter volume with resolution of compression symptoms of adjacent organs, reduction of the concentration of thyroid antibodies characteristic for patients with Graves' disease (TRAb), cure of hyperthyroidism in 71% of patients with thyrotoxicosis. Embolization procedure was not associated with the occurrence of undesirable side effects, such as the clinical symptoms associated with increased concentration of free thyroid hormones, and induction or exacerbation of pre-existing autoimmune thyroid disease. 2. Thyroid artery embolization had no significant influence on activity of the parathyroid glands, regardless of the number and quality of closed vessels. 3. Thyroid artery embolization is an effective and safe treatment of selected thyroid diseases as an alternative to conventional forms of therapy.

Intrathoracic Thyroid Solitary Fibrous Tumor Presenting with Respiratory Failure

Solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm that arises primarily from the pleura, but recognized also in other tissues. SFT in the thyroid gland is extremely rare. Here we presented the second reported SFT arising in an intrathoracic goiter. The88-year-old woman was referred with a huge goiter involving upper mediastinum accompanied by airway obstruction and tracheostomy. The patient underwent a left subtotal thyroidectomy, which revealed a SFT. No recurrence was noted during 3 years of follow-up.

Airway management of a difficult airway due to prolonged enlarged goiter using loco-sedative technique

Appropriate airway management is an essential part of anesthesiologist's role. Huge goiters can lead to distorted airway and difficulty in endotracheal intubation. In this report, we present a case of a 67-year-old woman with a huge toxic multinodular thyroid swelling, gradually increasing in size for last 20 years, where trachea was successfully intubated. She had a history of deferred surgery in June 2007 due to inability to intubate, despite 5-6 attempts using different laryngoscopes, bougie, and stylet. Patient was re-admitted in December 2011 for the surgery and was successfully intubated this time with help of fiberoptic intubation using loco-sedative technique. Patient was electively kept intubated postoperatively in view of chances of tracheomalacia due to prolonged large goiter. She was extubated successfully on post-op day 2 after demonstration of leak around trachea following tracheal tube cuff deflation. The different techniques of managing the difficult airway in these patients are discussed.

巨大な縦隔内異所性甲状腺腫の一例

巨大な縦隔内異所性甲状腺腫の一例

Iodotyrosine Deiodinase Defect Identified via Genome-Wide Approach

Diagnosis of congenital hypothyroidism is hampered by the heterogeneity of inborn errors of thyroid metabolism and the possible delay in hypothyroidism development leading to missed cases by neonatal screen. In the current study, we used a whole-genome approach to identify the mutation responsible for severe hypothyroidism and a huge goiter in the eldest child born to healthy first cousins. We identified a homozygous mutation of the iodotyrosine deiodinase gene (IYD). We delineated the phenotype of this defect in detail, including urinary monoiodotyrosine (MIT) and diiodotyrosine (DIT) excretion. Moreover, a 4.5-yr-old sister was found homozygous for the mutation. Her clinical and biological data were normal, except for elevated MIT and DIT excretion. The urinary loss of MIT and DIT iodine observed in most affected individuals was quite limited compared to the total iodine loss, except for the hypothyroid homozygote. Hypothyroidism could therefore be partially induced by a relative iodine deficiency caused by urinary iodine loss through MIT and DIT excretion, even in cases of normal iodine intake. The wide inter- and intrafamilial variability of the disease severity remains unclear. Besides refining the phenotype of the IYD defect, our observation shows that a global, genome-wide approach to the heterogeneous inborn thyroid defects was efficient in rapidly identifying the mutation in the proband and the disease recurrence in the still euthyroid sister. Although facilitated by consanguinity in this family, novel sequencing techniques will soon make whole-genome approaches readily amenable to more common cases.

Clinicopathological Profile, Airway Management, and Outcome in Huge Multinodular Goiters: An Institutional Experience from an Endemic Goiter Region

Huge goiters are common in iodine-deficient endemic regions. They are of concern to the surgeons because of the anticipated risk of difficult dissection and increased chances of surgical complications. Similarly, they are of concern to the anesthesiologists because of anticipated intubation-related difficulties and post-thyroidectomy tracheomalacia. In the present study we aimed to present our experience of managing goiters based on their gross weight, highlighting their clinicopathological profile, perioperative airway-related difficulties, and management of surgical morbidity. Retrospective analysis of patients who underwent total thyroidectomy in the primary setting at our institute from 1995 to 2009 was carried out based on the gross gland weight. The patients were thus grouped into group A: ≤200 g; group B: 201 to ≤400 g; group C: 401 to ≤600 g; group D: >600 g. Group A (660 cases); group B (108 cases); group C (36 cases); and group D (9 cases) were included. As the goiter size increased, the mean duration of goiter, compressive symptoms, retrosternal extension (RSE), airway deformity, intubation difficulty, and tracheomalacia increased. The rate of tracheostomy, sternotomy, hemorrhage, visceral injury, and hospital stay was high with huge goiters. These features were more marked in malignant goiters compared to benign goiters. However, the postoperative complications were comparable in both of those groups. Long-standing huge goiters are common in iodine-deficient endemic areas. The majority of patients have symptomatic or clinicoradiological evidence of airway involvement. The incidence of RSE, airway deformity, intubation difficulty, and tracheomalacia is high with huge goiters. The surgery is technically demanding with greater associated chances of injury to native structures. Malignancy influences the presentation and outcome in smaller goiters. In centers with experienced endocrine surgeons and dedicated anesthetists, huge goiters can be successfully managed with minimal short-term and long-term morbidity.

A case of bleeding esophageal varices caused by huge goiter

A case of bleeding esophageal varices caused by huge goiter

Preoperative Multidisciplinary Management of Airway Obstruction by Huge Goiter with Papillary Thyroid Cancer

Preoperative Multidisciplinary Management of Airway Obstruction by Huge Goiter with Papillary Thyroid Cancer

Goiter and Airway Control

ABSTRACT Goiter or thyroid swelling in neck has been known to be a risk factor for difficulty in airway management during anesthesia and surgery. The factors associated with difficult direct laryngoscopy and intubations in any patient are also the factors to predict difficult intubation in goiter patients. The huge goiter and long standing goiter especially with intrathoracic extension predispose for tracheomalacia. The tracheomalacia can be diagnosed during surgery but the airway obstruction usually develops after the extubation. Tracheostomy may be required in the event of loss of airway. A better understanding by surgeons and the anesthesiologists about the airway problems in goiter shall improve the outcome

A Case of Unilateral Thyroid Agenesis with Contralateral Huge Goiter

A unilateral thyroid agenesis that is found coexisting with a huge nodular goiter is very rare. We present a 43-year old woman with a recent history of a respiratory difficulty and a painless mass in the right side of her lower neck. A CT scan of her neck showed a 9×5 cm sized solid mass in the right infra-thyroid and thoracic area and left thyroid agenesis. The patient underwent surgery. The mass was identified as a structure separated from the right lobe of the thyroid, compressing the trachea. The histology revealed it to be a nodular goiter. The patient had an uneventful postoperative recovery and subsequently indicated euthyroid with normal normal calcium levels. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:313-5 Key WordsZZNodular goiter·Thyroid gland·Euthyroid.

Langerhans Cell Histiocytosis of the Lung and Thyroid, Co-Existing with Papillary Thyroid Cancer

A 24-year-old man presented to our center with a huge goiter compressing his airway. He had a previous diagnosis of Langerhans cell histiocytosis (LCH) of the lung. Core needle biopsy was consistent with histiocytosis. Thyroidectomy was performed. A very invasive mass was encountered at the time of surgery. Histopathology result was consistent with an invasive papillary cancer of thyroid co-occurring with LCH. Although association of LCH with different malignancies has been reported, co-existing invasive papillary thyroid cancer and LCH is a rare combination.

Invasion of the Recurrent Laryngeal Nerve by Tracheal Tumor

Vocal cord paralysis and goiter are 2 common problems encountered in otolaryngology practice. Their coexistence, however, should arouse suspicion of the presence of malignant thyroid disease. Primary tracheal cancer is uncommon, and its incidence is very low compared with laryngeal cancer. Primary tracheal tumors can cause recurrent nerve palsy. We report here a rare case of vocal cord paralysis caused by a clinically occult tracheal squamous cell carcinoma in an 80-year-old patient with coincidental huge multinodular goiter.

Adaptation of Median Partial Sternotomy in Head and Neck Surgery

Upper mediastinum involvement in diseases of the head and neck may require a sternal split. This study describes our adaptation of the upper median or "minimal" sternotomy technique for the treatment of head and neck pathologies. Between April 2002 and October 2005, 17 patients aged 4 to 82 years underwent minimal sternotomy in our institution for a variety of head and neck pathologies. The 17 patients included 11 adults with metastatic thyroid disease (six metastatic papillary thyroid carcinoma, two medullary carcinoma, and one Hiirthle cell carcinoma) and huge retrosternal goiter (n = 2), four adults with parathyroid disease (two primary parathyroid adenoma, one secondary hyperplasia, and one parathyroid carcinoma), and two children with lymphangioma and huge thymic cyst (one each). Average hospitalization was 8 days. Four patients needed a thoracic drain for 2 days, one had recurrent laryngeal nerve palsy, and one had phrenic nerve paresis. There were no postoperative deaths. Minimal sternotomy appears to be an excellent alternative for surgical exploration of the mediastinum and may be used in head and neck surgery for a range of indications.

A Case of Resected Huge Goiter With the Temporal Placement of a Dumon Stent

An 86-year-old woman with a 30-year history of goiter was hospitalized with severe stridor and progressive dyspnea on exertion that had worsened over the past year. The trachea was severely compressed by a huge mass, measuring 15 cm in diameter, on the left side of her neck. For the prevention of postoperative instability, a Dumon stent was placed in the trachea for 3 days. The postoperative course was uneventful and she was discharged on day 32. With the temporal placement of the Dumon stent, the airway became secured and early ambulation was possible. We prefer temporal Dumon stent placement for patients at risk for tracheomalacia who have marked tracheal stenosis, especially in the elderly, instead of either prolonged intubation or performing a tracheostomy.

Difficult Airway In A Morbidly Obese Patient With Huge Goiter: A Case Report And Review Of Literature

Huge goiters can lead to tracheal compression and hence difficulty in endotracheal intubation. In this report we present a case of a huge goiter presented with difficult airway where the trachea was successfully intubated. A 51-year-old female patient presented to our hospital with shortness of breath due to huge goiter compromising the airway. Her body weight 100 Kg with body mass index (BMI) of 50 Kg/m. The patient was scheduled to undergo total thyroidectomy. Clinical examination revealed morbid obese patient with orthopnea (she cant lie supine in bed). She was receiving oxygen via nasal cannula 3l/min. Airway assessment showed short bulky neck with Mallampati class IV. Thyromental distance could not be estimated due to the tumor size and due to limited neck movements. The trachea anteriorly could not be palpated except of 1 inch at the cricoid level. The plan was to intubate the trachea using fiberoptic bronchoscope (FOB). If fails or if the patient lost the airway secondary to topical anesthesia plan B was to insert minitracheotomy in the space felt at cricoid ring and rescue the airway by insufflation of oxygen or alternatively intubating the trachea via rigid bronchoscopy. Awake FOB was successfully performed to intubate the trachea. Extubation of the trachea was performed in the operation room using airway exchange catheter. In conclusion, the only viable option in our case was awake FOI which was well tolerated. We believe that preoperative airway assessment could predict patients with possible difficult airway. Also preoperative explanation to the patient about the risks encountered with co morbidities remain an essential step prior to awake FOI. Proper planning and discussing the problems with the patient and surgeon are important for safe outcome. Extubating the trachea of those patients in controlled atmosphere in the OR is essential to rescue the airway if tracheal collapse occurs. Finally, issuing a medical alert card is important precaution measurement for subsequent anesthetic exposures.

High Incidence of Thyroid Cancer in Long-Standing Goiters with Thyroglobulin Mutations

In this paper, we report the high prevalence of thyroid malignancy in patients with thyroglobulin mutations in Japan. Mutations of the thyroglobulin gene cause defective thyroid hormone synthesis, resulting in congenital hypothyroidism. Since our report in 1999 on the thyroglobulin mutations C1264R and C1996S, we have identified 14 adult patients (7 males and 7 females) from 9 unrelated families. They visited hospitals for treatment of huge goiters that first appeared in childhood. Persistent growth of the thyroid gland, probably caused by thyrotropin (TSH) stimulation, partially compensated thyroid hormone production, resulting in lowered serum TSH concentrations in turn. Consequently, many patients had to undergo multiple operations. Of 11 patients who had undergone surgery, 7 had thyroid cancers. Of five patients whose thyroid tissue was available, we found a heterozygous activating mutation, either V599E or K600E, in cancerous tissue from each of 2 patients. From these observations, we conclude that goiter resulting from thyroglobulin mutations is associated with thyroid cancer.

Anesthetic Management of Huge Goiter with Retrosternal Extension

Goiter is a known risk factor for difficult airway management. We report the anesthetic management of a case with a huge multinodular goiter which compromised the airway with retro-sternal extension and tracheal compression.