Large Retrosternal Goiter Research Articles

Minimal Invasive Resection of Large Retrosternal Thyroid Goiter.

Resecting a large goiter extending into the retrosternal space is challenging, especially when a sternotomy or thoracotomy is required. The transthoracic approach is linked to higher postoperative morbidity, reaching up to 30% when compared to the transcervical approach. Although alternative options like thoracoscopic resection have shown promising results, the morbidity of mediastinal dissection remains a concern. Thoracoscopic-assisted transcervical approach might be a feasible, less invasive alternative. This video outlines the steps and potential pitfalls of the procedure. The patient is positioned supine with an extended neck. Initially, the endocrine surgeon mobilizes the thyroid gland through cervical access. If a transcervical resection is not feasible, the patient is mobilized into a lateral decubitus position, and a second team thoracoscopically guides the mediastinal tumor through the thoracic inlet. This allows a stepwise controlled transcervical dissection of the retrosternal mass until complete resection is achieved, thus eliminating the need for mediastinal dissection. To demonstrate the procedure, we present the case of an 84-year-old male with lymph node-positive oncocytic thyroid carcinoma and a large retrosternal goiter extending posteriorly into the mediastinum up to the aortic arch. Thoracoscopic-assisted transcervical resection was performed. The recurrent laryngeal nerve was identified and monitored with a neurostimulation device during dissection. No palsy was noted in the postoperative evaluation. The patient had an uneventful postoperative course and was discharged on the second postoperative day. Thoracoscopic-assisted transcervical resection of large retrosternal goiter seems a feasible alternative to mitigate risks associated with thoracotomy, sternotomy, or thoracoscopic mediastinal dissection. Potential advantages include decreased postoperative morbidity and length of stay. This technique requires thoracoscopic expertise and may be limited depending on the goiter's size and mediastinal positioning.

ThP2.8 - Reducing postoperative length of stay after thyroidectomy through a standardised multidisciplinary postoperative care protocol does not compromise patient safety

Abstract Aims Our unit had a significantly longer length of stay after thyroid surgery. We introduced change of practice through a standardised multidisciplinary postoperative care protocol. We analyse the effect of the protocol on postoperative length of stay and any impacts on patient safety. Methods A multidisciplinary protocol was implemented and embedded into clinical practice. Data was collected prospectively on consecutive patients undergoing thyroid surgery. Outcomes with reference to adverse events, length of stay and readmissions were audited. Comparisons were made with unit's pre-protocol data and national figures published in BAETS (British Association of Endocrine and thyroid Surgeons) audit report. Results A total of 78 patients underwent 37 total thyroidectomies and 41 lobectomies. Three (8.3%) of the total thyroidectomies had transient hypocalcaemia but none were permanent. None had voice changes or recurrent laryngeal nerve palsy. Three patients were reviewed few days after discharge with mild hypocalcaemia symptoms treated with calcium supplements. One was re-admitted 5 days post discharge with wound infection. Twenty-seven (75%) were discharged on 1st postoperative day as opposed to 0% pre-protocol (BAETS audit report 66%). Thirty-seven (90%) of lobectomies were discharged on 1st postoperative day (Units pre-protocol 42%, BAETS audit 81%). There was no postoperative bleed or hypocalcaemia. One patient with a large recurrent retrosternal goitre had transient recurrent laryngeal nerve palsy that recovered subsequently. There were no readmissions or adverse events directly related to early discharge. Conclusion A well embedded dedicated postoperative care protocol can significantly reduce postoperative hospital stay after thyroid surgery without compromising patient safety.

Challenges for a perioperative physician – A choking thyroid planned for total thyroidectomy

A large retrosternal goiter is a nightmare for an anesthesiology and a surgeon. A comprehensive history, a thorough clinical examination, pre-operative planning and a close working relationship among multidisciplinary medical teams are prerequisites to prevent adverse events intra-operatively and postoperatively. This case report is about a geriatric patient who presented with progressively enlarged anterior neck swelling for past 30 years associated with orthopnea and dysphagia. Patient underwent awake fibreroptic intubation under topical anesthesia. Thyroidectomy combined with sternotomy was done. Intra-operative and postoperative was uneventful.This case report suggests the use of AFOI in anticipated difficult airway and it’s success.

Airway management of a neurofibromatosis type 2 with multicompartmental tumours: a case report

Neurofibromatosis type 2 (NF2) is a rare autosomal dominant disorder. We report a case of a 52-year-old woman with underlying NF2 who was scheduled for excision of cervical neurofibromas. The patient had four nerve sheath tumours affecting different parts of the airway, namely, two cervical neurofibromas with spinal cord compression, a large retrosternal goitre extending into the anterior mediastinal compartment causing central airway obstruction, and a large left thoracic paravertebral tumour in the posterior mediastinal compartment. After risk stratification and multidisciplinary discussion, awake nasal fibreoptic intubation with a contingency plan of rigid bronchoscopy and jet ventilation was decided. The patient was intubated successfully with target-controlled infusion remifentanil as the sole sedative and airway topicalization with local anaesthetic. The patient was ventilated in a prone position intraoperatively with no desaturation. The tumours were successfully removed and the patient was discharged well. Awake nasal fibreoptic intubation is the choice of management in difficult airways affected by multicompartmental tumours in a centre that is devoid of extracorporeal membrane oxygenation service.

Retrosternal goitre: Anaesthetic implications and management

Large retrosternal goitre is a challenge to the anaesthesiologist and the surgeon. We describe the successful anaesthetic management of a 44 year old male patient with extensive retrosternal goitre with severe tracheal compression, operated for total thyroidectomy under general anaesthesia by combined cervical approach and sternotomy. A multidisciplinary team approach with surgical colleagues allowed successful management of the patient. Keywords: Retrosternal goitre, Thyroidectomy, Sternotomy, Awake fibreoptic intubation.

SUN-574 Exogenous Iodine Supplementation-Induced Thyroid Storm in a Patient with Multinodular Goiter

Introduction: Iodine is an essential micronutrient for thyroid hormone synthesis. Its primary source is fortified foods. Supraphysiologic doses of iodine are often found in iodine supplements that are advertised to support thyroid metabolism and reduce goiter size. Normally, excess iodine temporarily inhibits production of thyroid hormone (Wolff-Chaikoff effect), causing goiter and hypothyroidism. In patients with a pre-existing nodular goiter, the auto-regulation of iodine entry into thyroid cells and thyroid hormone synthesis are ineffective. Exposure to high doses of iodine in such cases can precipitate hyperthyroidism (Jod-Basedow phenomenon). Clinical Case: A 50 year-old lady with morbid obesity, chronic lymphedema, longstanding hypothyroidism, and a large retrosternal goiter presented with severe sepsis from cellulitis and tachycardia-induced cardiomyopathy (ejection fraction 30%) from a new-onset atrial flutter with rapid ventricular rate requiring cardioversion. Free (f)T4 was 4.81 ng/dL (0.93-1.7), fT3 6.0 pg/mL (2.0-4.4) and TSH 0.006 mcu/mL (0.27-4.2). Two years ago, she was seen by endocrinology, at which time TSH was 1.58 mcu/mL on desiccated thyroid 30 mg qd. Due to substernal goiter, surgery was recommended then but declined by the patient. Later, she increased desiccated thyroid to 60mg qd and started OTC iodine supplements at 30,000 mcg qd (20,000% RDA) of her own volition, hoping to decrease the size of the goiter. The patient was subsequently lost to follow-up. On this admission, hospital course was complicated by disseminated intravascular coagulation, acute kidney injury needing renal replacement therapy (RRT), encephalopathy, and mechanical ventilation. CT and US demonstrated stable heterogeneous, multinodular goiter (12.5 x 9.3 cm with mediastinal extension), without prominent vascularity. Treatment with PTU, beta-blockers, hydrocortisone, and cholestyramine was initiated on day 1. Serum iodine was markedly elevated at 2,160 ng/ml (40-92) and improved to 221 ng/ml after six days of RRT. Despite PTU 300mg q6h for > 3 weeks, fT4 remained elevated. Eventually fT3 and fT4 normalized to 2.1pg/mL and 1.30ng/dL, respectively, with continued improvement in iodine level. TSH remained undetectable. Severe medical comorbidities precluded surgical resection of the goiter. Conclusion: Dessicated thyroid hormone, markedly supraphysiologic iodine intake, and thyroid autonomy characteristic of MNG contributed to life-threatening thyrotoxicosis in this patient. Extremely high iodine content in the blood and thyroid undoubtedly impeded therapeutic response to PTU, and RRT helped to lower systemic iodine load. This case demonstrates the importance of careful history taking to identify unusual sources of iodine in patients, and patient education regarding possible dangers associated with unregulated OTC and dietary supplements.

THYROID SURGERY

Objectives: The present prospective observational study was conducted to determine frequency and thyroid conditions as likely risk factors for hypocalcaemia following thyroid surgery. Study Design: Observational study. Place and Duration: Department of surgery, Liaquat University Hospital from December 2011 to December 2015. Materials and Methods: A sample of 201 patients, undergoing thyroid surgery with bilateral exploration, was selected according to criteria. Pre operative clinical work up was conducted for patient history, neck examination, thyroid hormone assay, serum calcium, Technetium99 thyroid scanning, laryngoscopy and sonography. Serum Ca++ was estimated before and after thyroid surgery.Hypocalcaemia was defined as calcium level <8 mg/dl. Data was analyzed on SPSS 22.0 (IBM, incorporation, USA) at 95% confidence interval. Results: Of 201 patients, male and female were noted as 93 (46.2%) and 108 (53.7%) respectively. Female to male ratio was 1: 0.86. Mean± SD age was noted as 42.3 ± 7.4 years. Overall frequency of hypocalcaemia was identified in 23 (11.4%) of subjects. Mean± SD serum calcium in hypocalcemia subjects was noted as 7.1 ± 0.78 mg/dl. Symptomatic hypocalcaemia was noted in 11 (5.4%) of total subjects. Conclusion: In the present study, an overall frequency of hypocalcaemia was identified in 23 (11.4%) of subjects. Large goiters, recurrent goiter, retrosternal goiter, hyperthyroidism and Grave’s disease were noted as risk factors.

Venovenous-ECMO as a tool in airway management in a patient with large retrosternal goiter

Venovenous-ECMO as a tool in airway management in a patient with large retrosternal goiter

Are Downhill Varices an Overlooked Entity of Upper Gastrointestinal Bleedings?

Aim Downhill varices are not so safe as thought and can lead to life-threating or mortal bleeding complication, even if rare. In order to draw attention to this topic, we analysed 129 patients. Materials and Methods We evaluated the electronic endoscopy data records of all patients undergoing upper gastrointestinal endoscopy over a nine-year period from January 2004 till December 2012, within a retrospective approach. The primary endpoints, incidence, causes, kind of resulting upper gastrointestinal bleeding, and the severity of the bleeding were evaluated. Secondary endpoints were the evaluation of the size of downhill varices and a comparison of the risk of bleeding between downhill varices and uphill varices. Results Downhill varices were identified, described, and/or documented in 129 patients of 25,680 upper gastrointestinal endoscopies. 26 patients had central venous catheter or port implantation, 22 patients had a history of an implantation of a cardiac pacemaker, 7 patients had severe pulmonary artery embolism, and 4 patients had severe chronic obstructive pulmonary disease. Two patients had mediastinal tumors, and one patient had a large retrosternal goiter as a possible cause of the vena cava syndrome. Altogether, 62 patients were related to a vena cava superior syndrome; 67 were not. Conclusions Downhill varices can be seen with an incidence of 0.5%. Therapeutic means are the banding therapy as a safe and effective option. Severe bleedings associated with downhill varices can be mortal. Severe forms of downhill varices should be examined in relation to the origin in order to start a specific therapy.

Does a combined procedure for cardiac surgery and thyroidectomy offer acceptable outcomes?

This best evidence topic on cardiothoracic surgery was written using a structured protocol. The question addressed was: 'in an adult patient requiring cardiac surgery, can a thyroidectomy for a large retrosternal goitre be performed with good outcomes as a combined procedure?' Of 150 papers identified through the literature search, 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, study type, patient group studied, relevant outcomes and results were tabulated. This paper includes 3 Level 4 papers and 13 case reports. All papers reported postoperative outcomes and five papers reported intraoperative outcomes. Of a total cohort of 32 patients, 25 were euthyroid prior to combined surgery. Twenty-nine of 32 thyroid surgeries were performed immediately prior to cardiac surgery in the combined procedure sequence. Post-procedural complications including transient recurrent laryngeal palsy and tracheomalacia were reported in 8 patients. There was one intraoperative death. Where reported, all patients were euthyroid on follow-up. All identified papers reported good outcomes with combined thyroidectomy and cardiac surgery.

Broken heart syndrome triggered by an obstructive goiter not associated with thyrotoxicosis

Takotsubo cardiomyopathy (TC) is described as transient ventricular dysfunction following emotional or physical trauma. A few reports have described patients with TC in association with various circumstances of thyrotoxicosis. We report an unusual case of TC in a patient with a large retrosternal goiter and normal thyroid function. We speculate that TC was triggered by compromise of tracheal flow induced by the goiter. A 68-yr-old woman without primary heart disease presented with cardiorespiratory collapse requiring ventilatory and cardiovascular support, including placement of an intra-aortic balloon pump. She was diagnosed with a severe form of TC based on characteristic echocardiography findings and clinical course. Within less than a week, her myocardial function completely normalized. The patient was later found to have a large retrosternal goiter compressing her trachea, though her thyroid function was normal. A total thyroidectomy was eventually performed, and she made a full recovery. Subsequently, the patient was found to have a positive JAK2 mutation for a myeloproliferative disorder. Takotsubo cardiomyopathy may be regarded as the final common pathway of cardiac dysfunction triggered by various stress conditions, in this case, a large retrosternal goiter not associated with thyrotoxicosis and likely exacerbated by severe leukocytosis related to a myeloproliferative disorder.

Remnant Large Retrosternal Thyroid Goiter after Thyroidectomy

Remnant Large Retrosternal Thyroid Goiter after Thyroidectomy

Primary intrathoracic goiter: Incidental diagnosis on 99m-Tc pertechnetate radioisotope thyroid scan

Primary intrathoracic goiter: Incidental diagnosis on 99m-Tc pertechnetate radioisotope thyroid scan

The Nonrecurrent Laryngeal Nerve in Thyroid Surgery

ABSTRACT A nonrecurrent laryngeal nerve is a rare anomaly and estimated to be present in 0.25 to 0.99% of patients.1 The identification and preservation of the recurrent laryngeal nerve is an essential part of thyroid surgery. It is now well-known that the recurrent laryngeal nerve is not only a single nerve but also a complex branching network of innervation. Thyroid surgery demands a precise understanding of the anatomical intimacy between the gland and surrounding structures, including the parathyroid glands and neurovascular tissue. The morbidity associated with thyroid surgery, in the short-term, generally relates to hematoma collection and hypocalcemia. Long-term morbidity is more commonly seen with dysphonia and vocal cord dysfunction due to superior laryngeal nerve damage and its role in explosive sound formation, the recurrent laryngeal nerve, its tortuous anatomical course, and its role in laryngeal musculature innervation. We review the literature on this subject and report three cases of the rare nonrecurrent anomaly, firstly a 75-year-old lady with a large retrosternal goiter. During her initial work-up which included a CT scan of the thorax, an ‘arteria lusoria' was identified in the retroesophageal plane. Intraoperatively, a right-sided nonrecurrent inferior laryngeal nerve (NRILN) was identified. The second case is of a 63-year-old lady with a right-sided type 1 nonrecurrent laryngeal nerve which we identified and photographed when medially retracting the gland off the central compartment and ligament of Berry. The third case is that of a 45-year-old lady with a right-sided thyroid nodule and a right-sided NRILN identified intraoperatively.

Pemberton’s Sign in Patient with Substernal Goiter

A 62-yr-old man with a long history of goiter was referred to the physician due to progressive dyspnea and stridor on exertion. The patient has slept on his left side to improve breathing. Physical examination revealed an enlarged left lobe of the thyroid, but a lower pole was not palpable. After elevation of both of his arms, marked facial plethora developed, indicating compression of the jugular veins (Pemberton’s sign) (Fig. 1, A and B). The patient was euthyroid. Noncontrast computed tomography of the neck revealed a large goiter of the left thyroid lobe and isthmus, with longitudinal diameter 11 cm, transversal 6.5 cm, and anteroposterior 5 cm. The left common carotid artery and jugular vein were dislocated laterally and posterior. Tracheal stenosis was present at the level of the thoracic inlet. The patient was sent to surgery and successfully operated. Total thyroidectomy was performed. Pathohistology revealed nodular colloid goiter. Pemberton’s sign may be found in patients with a large mediastinal mass, usually with large retrosternal goiter (1, 2) or tumor. Hugh Spear Pemberton described the sign in a letter to Lancet in 1946 (3). Although contrast-enhanced computed tomography provides better visualization of neck and mediastinal structures, it may be contraindicated in patients with large goiter because the use of iodinated radiographic contrast agents may provoke iodine-induced hyperthyroidism (4). The Pemberton maneuver should be used as an addition to physical examination of substernal goiter, especially in patients with symptoms of compression. This sign indicates compression of vascular structures in the thoracic inlet that warrants more urgent treatment. Acknowledgments

Unusual case of initial failure of pacemaker implantation

Central venous obstruction sufficient to prevent primary pacemaker implantation is rare. We report on such a patient in whom removal of a very large retrosternal goitre led to subsequent procedural success.

Recurrent Unexplained Episodes of Facial Cyanosis and Shortness of Breath in Hunter Disease

A 12-year-old boy affected by Hunter disease (mucopolysaccaridosis type II) was referred with a history of recurrent episodes of cyanosis and shortness of breath. Physical examination disclosed the typical features of the condition, but was unremarkable for any cardiopulmonary abnormality. Careful clinical observation of the boy revealed that cyanosis was limited to his face and developed, with shortness of breath and venous cervical engorgement, within 30 seconds after elevating his arms (Figure). In 1946, H.S. Pemberton first described in a patient with a large retrosternal goiter that extension of both arms above the head was followed by facial plethora with distended neck veins and shortness of breath with stridor. The observation, which is now called positive Pemberton sign, reflects vascular and airway compromise developing when the thoracic inlet becomes obstructed by a large mass extending retrosternally. It is common in retrosternal goiter, but may also occur with lymphoma, thymoma, lung carcinoma, or aortic aneurysm. In our patient a conventional chest radiography examination disclosed 2 enlarged clavicles, a recognized finding in Hunter disease, but without any mediastinal enlargement. Typical airway concerns in Hunter disease include tongue enlargement, pharyngeal hypertrophy, supraglottic edema, and deformation of the trachea. This case indicates that in Hunter disease positional changes sometimes result in vascular and airway compromise. Thus, we propose to test the Pemberton sign in children with Hunter disease and in children with positional symptoms of the head and neck.

The Management of a Patient With Tracheal Compression Undergoing Combined Resection of an Anterior Mediastinal Mass and Aortic Valve Replacement With Coronary Artery Bypass Graft Surgery: Utility of the Laryngeal Mask Airway and Aintree Intubation Catheter

T HAS LONG BEEN recognized that the presence of an anterior mediastinal mass can lead to respiratory and cardiovascular collapse. Importantly, the severity of airway compromise may not be apparent in the awake patient. There have been numerous reports in the literature of life-threatening complications or death during anesthetic induction, maintenance, and emergence, as well as in the early postoperative period. 1,2 Symptoms attributable to anterior mediastinal masses include airway compression with obstruction, obstruction of the major vessels and heart, and superior vena cava syndrome. 3,4 Airway management in these patients can prove challenging and demands proper planning and communication on the part of the anesthesia and surgical teams. This case describes the airway management of a high-risk patient with significant tracheal narrowing and a large retrosternal goiter undergoing combined resection of this mass with major cardiac surgery. CASE REPORT A 54-year-old woman presented with a 3-day history of shortness of breath, cough, and an inability to lie flat because of worsening dyspnea. Past medical history was significant for morbid obesity (weight 112 kg, height 162 cm), emphysema, angina, hypertension, non‐insulin-dependent diabetes mellitus, anxiety/depression, hyperlipidemia, osteoarthritis, gastroesophageal reflux, gastroparesis, and a more than 30 pack/year current smoking history. Two years earlier, she had undergone emergency tracheostomy for upper-airway obstruction after a dental infection. This was complicated by acute respiratory distress syndrome requiring mechanical ventilation for 2 weeks. Medications at the time of presentation included lasix, potassium chloride, prednisone, Nexium (AstraZeneca LP, Wilmington, DE), Lipitor (Pfizer Inc, New York, NY), Singulair (Merck, Whitehouse Station, NJ), Diovan (Novartis, Cambridge, MA), Lexapro (Forest Laboratories, New York, NY), reglan, Allegra (Sanofi Aventis, Bridgewater, NJ), Vioxx (Merck), Paxil (SmithKline Beecham, Philadelphia, PA), metoprolol, and albuterol. A computed tomography scan of the chest showed an enlarged thyroid gland extending down into the superior mediastinum and surrounding the upper trachea. The trachea was maximally narrowed to 5 mm at the level of the thyroid cartilage (Fig 1), with intrathoracic extension of airway narrowing. A transthoracic echocardiogram showed a left-ventricular ejection fraction of 55%, left-ventricular hypertrophy, mild mitral regurgitation, severe aortic insufficiency, and a small pericardial effusion. Cardiac catheterization revealed a 70% proximal left circumflex coronary artery stenosis. Pulmonary function tests showed the following: forced expiratory volume in 1 second of 1.3 L (61% predicted), forced vital capacity of 1.8 L (68% predicted), forced expiratory volume in 1 second/forced vital capacity of 72.3%, and FEF25-75 (forced expiratory flow from 25% to 75% of vital capacity) of 0.75 L/s (28% predicted). Spirometry showed flattening of the expiratory limb of the flow-volume loop (Fig 2). Laboratory data including complete blood count, electrolyte panel, coagulation profile, and thyroid function studies were all within normal limits. The patient was premedicated intravenously with midazolam, 1 mg, glycopyrollate, 0.2 mg, ranatidine, 50 mg, and metaclopromide, 10 mg. Preoperatively, her airway was anesthetized with 4 mL of nebulized 4% lidocaine. Intraoperative monitors included the standard American Society of Anesthesiologists monitors, a brachial arterial catheter, and a pulmonary artery catheter that was placed after intubation. Bilateral glossopharyngeal nerve blocks were performed by using 1% lidocaine. For anesthetic induction, she was maintained in 30 degrees of reverse Trendelenburg positioning and preoxygenated for 5 minutes. Eighty milligrams of propofol were administered, and a no. 4 laryngeal mask airway (LMA) was easily inserted. The patient maintained spontaneous respiration during this time, and sevoflurane was incrementally administered to 2.3% end-tidal concentration. With the patient breathing spontaneously, a fiberoptic bronchoscope loaded with an Aintree intubation catheter (Cook Critical Care, Bloomington, IN) was introduced into the trachea via the LMA by using a swivel adaptor to allow continued delivery of oxygen and sevoflurane. The Aintree intubation catheter is an airway-exchange catheter with a 4.8-mm internal diameter that can be loaded onto a 4.0-mm fiberoptic bronchoscope. The vocal cords were sprayed with 1% lidocaine through the suction port of the bronchoscope, the airway was examined for degree of patency, and the catheter was easily advanced across the narrowed portion of the trachea. The LMA was then removed, and a 7.0 armored endotracheal tube was gently advanced over the intubating catheter past the obstruction. After median sternotomy, the patient underwent total thyroidectomy, breathing spontaneously. End-tidal CO2 ranged between 40 and 50 mmHg, and PaCO2 measured during spontaneous ventilation was 47 mmHg. The surgeon confirmed by direct palpation that there was no tracheomalacia. Pancuronium was then administered, and the patient underwent uneventful aortic valve replacement and single-vessel coronary artery bypass grafting to the left circumflex coronary artery with cardiopulmonary bypass. She remained intubated overnight and was extubated the next morning after having met standard extubation criteria and the demonstration of a leak around the endotracheal tube with cuff deflation. Her postoperative course was uneventful, and she was discharged on postoperative day 6 with significant improvement in her respiratory complaints.

Retrosternal goitre: a cause of dyspnoea in pregnancy

During pregnancy, the thyroid undergoes several changes including altered function and gland enlargement. We describe the management of a 38-week pregnant woman presenting with cough and increasing breathlessness. She gave a 5-year history of asthma which initially obscured the final diagnosis of upper-airway obstruction secondary to tracheal compression by a large retrosternal goitre. Once this was recognized, management was straightforward. Delivery by caesarean section was carried out under epidural anaesthesia, following which her symptoms rapidly resolved. A subtotal thyroidectomy was performed 4 weeks later under general anaesthesia, again without incident. We outline the normal physiological changes that occur to the thyroid gland during pregnancy and also highlight the value of the flow volume loop in the evaluation of airway obstruction.

Retrosternal Goiter Associated With Chylothorax

We describe a case of chylothorax in a female patient with a large retrosternal goiter. After subtotal thyroidectomy by means of a Kocher cervicotomy, the chylothorax disappeared in 48 h. At present, 2 years after surgical removal, the patient remains asymptomatic, without recurrent pleural chylous effusion. Until now, to our knowledge, only one such case had been reported.