Mediastinal 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.

A rare case report of accessory thyroid in the superior mediastinum in the form of multinodular goiter

Retrosternal expansion of a goiter is one of the most common types of mass in the upper mediastinum. Although there is no clear definition of retrosternal, substernal, or mediastinal goiter in the literature, it usually refers to an extension of thyroid tissue from the cervical part that continues to the anterior mediastinum of the aortic arch. One of the interesting features of these cervical mediastinal lesions is that they may not be continuous. Such goiter types classically present with compression symptoms such as dyspnea, dysphonia, dysphagia, or sleep apnea, and less frequently, these masses can compress neurovascular structures, leading to superior vena cava (SVC) syndrome and Horner’s syndrome. In our case report, A 47-year-old female from North Karnataka presented to the hospital with history of dyspnea, dysphonia, and dysphagia persisting for the last 3 years. After careful examination and investigation, a diagnosis of thymoma was made initially. However, upon biopsy of the excised tumor, unexpected finding was revealed, it was identified as a multinodular goiter (MNG) rather than a thymoma.

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.

Electrophysiological monitoring of the nonrecurrent inferior laryngeal nerve and radiological evaluation of concurrent vascular anomalies.

The objective of this study was to characterize the electrophysiological characteristics of nonrecurrent inferior laryngeal nerves (NRILNs) that were dissected via intraoperative neuromonitoring (IONM) and concomitant vascular anomalies in patients with NRILNs. A retrospective analysis was conducted on 7865 patients who underwent thyroidectomy with IONM at three tertiary referral centers. The study included 42 patients in whom an NRILN was detected. IONM data and postoperative vocal cord (VC) examinations were recorded for all patients. The absence of an initial vagal EMG response and/or a short (<3.5 ms) latency period during the initial vagal stimulation or the inability to identify the RLN within the Beahrs triangle was considered highly suspicious for the presence of an NRILN. Postoperative cross-sectional imaging was performed in 36 out of 42 patients to assess any concurrent vascular anomalies. The prevalence of NRILN was 0.53%. An NRILN was suspected due to EMG findings in 32 (76%) patients and the inability to identify the RLN within the Beahrs triangle in the remaining 10 (24%) patients. The mean right VN latency period was 3.05 ± 0.15 ms. The V1 latency period of the right VN was shorter than 3.5 ms in 39 (93%) and longer than 3.5 ms in 3 (7%) patients. One of these three patients with latency>3.5ms had a large mediastinal goiter. Transient VC paralysis occurred in one (2.4%) patient. Of the 36 patients with postoperative imaging data, 33 (91.4%) had vascular anomalies. All 33 patients had aberrant right subclavian arteries, and 13 (39.4%) also had accompanying additional vascular anomalies. The NRILN is an anatomical variation that increases the risk of nerve injury. Observation of an absent EMG response and/or a short latency period during the initial vagal stimulation facilitates the detection of an NRILN at an early stage of thyroidectomy in the majority of patients.

FRI504 Ectopic Hyperactive Mediastinal Thyroid Tissue: A Case Report

Abstract Disclosure: C. Dimech: None. G. Jaiswal: None. A. Bhargava: None. Ectopic thyroid tissue is usually located along the normal path of the caudal migration of thyroid tissue during embryonic life. Substernal goiters are thought to occur by either the enlargement of ectopic mediastinal thyroid tissue (primary mediastinal goiter) or abnormal extension of thyroid issue into the superior mediastinum (secondary mediastinal goiter). Typically these goiters remain asymptomatic, and rarely result in hyperthyroidism or local compression of the surrounding area. We report a case of an 89-year-old Caucasian female with history of a multinodular goiter status post right hemithyroidectomy, who initially presented for subclinical hyperthyroidism. Further evaluation revealed negative thyroid stimulating antibodies. A thyroid ultrasound demonstrated a surgically absent right lobe, with a small heterogenous left lobe. A nuclear medicine radioactive iodine uptake and scan showed hypermetabolic residual thyroid tissue with a large area of increased radiotracer uptake projecting over the right anterior chest, concerning for ectopic thyroid tissue. A subsequent chest CT without contrast revealed an approximately 5 centimeter partially calcified anterior mediastinal/retrosternal mass. Given the patient’s age and co-morbidities, a decision was made to treat the hyperthyroidism with methimazole and monitor the ectopic tissue for worsening symptoms of compression. In cases with severe compressive symptoms, or difficult to treat hyperthyroidism, a surgical option must be considered. Presentation: Friday, June 16, 2023

Successful excision of a giant cervical mediastinal goiter by cervical collar incision and a thoracoscopic approach: a case report

BackgroundGiant cervicomediastinal goiter extending to the bifurcation of the trachea mostly requires median sternotomy in addition to a cervical collar incision for resection. Sternotomy provides a good operative field, although it is one of the most invasive thoracic approaches. We herein report a case of giant cervicomediastinal goiter resected by a less-invasive and highly effective method with a thoracoscopic and cervical approach.Case presentationA 71-year-old Japanese woman with giant cervicomediastinal goiter extending to the bifurcation of the trachea was introduced and admitted to our hospital with dyspnea. Chest computed tomography showed tumor-induced airway narrowing due to the giant goiter of the right side of the thyroid lobe. We safely performed resection of the giant goiter through a cervical collar incision and thoracoscopic approach, and this combined approach contributed to the early discharge of the patient from the hospital.ConclusionA combined approach of cervical collar incision and thoracoscopy is useful for resection of giant goiter.

Mediastinal goitre - a South African case series.

Mediastinal goitres are rare and may be diagnosed late since they are likely to manifest with non-specific cardiorespiratory symptoms especially when there is no visible cervical component. The imaging modality of choice is a contrast-enhanced computed tomography (CT) scan of the neck and chest after incidental finding of goitre on chest X-ray indicated for a condition unrelated to goitre. This case series aims to highlight the peculiarity of mediastinal goitre in terms of clinical presentation, surgical approach, airway challenges at anaesthesia, specific complications and final histopathological report. Over a nine-year period, four cases of euthyroid mediastinal goitre underwent sternotomy. The mean age was 57.5 years (45-71) and all patients were female. Most patients presented with non-specific cardiorespiratory symptoms. The difficult airway set was used in all cases and there were two instances of damage to the recurrent laryngeal nerve (RLN). All histopathological reports were benign. The presentation of the mediastinal goitres was atypical. Cervical incision and sternotomy were performed in all cases. There were two instances of RLN injury and no malignant histopathology. Despite the potential threat to the airway, all intubations were uneventful.

Mediastinal Goiter from the View of Thoracic Surgery

Mediastinal Goiter from the View of Thoracic Surgery

A Giant Posterior Mediastinal Goiter

Goiter is defined as abnormal (either nodular or diffuse) growth of the thyroid gland. The normal thyroid gland is located in neck, caudal to larynx in anterolateral portion of the trachea. Intrathoracic goiter, defined as growth of more than 50% of the thyroid gland below the thoracic operculum, mostly located in anterior mediastinum and is seen in only 8%–15% of all goiters. Posterior mediastinal goiters (PMGs) are rare and accounts for only 2% of intrathoracic goiters. Patients usually present with a cervical mass and local pressure symptoms due to tracheal, esophageal, or superior vena cava compression. The diagnosis is established by chest X-ray, computed tomography scan, and fine-needle aspiration cytology. A combined cervicothoracic approach is the procedure of choice as it provides easy access, better visualization, and optimal control of blood vessels. We, hereby, describe a case of giant PMG, which was managed successfully at our center.

Mediastinal aberrant goiter characterized by high radiodensity on non-enhanced computed tomography: a case report

BackgroundA mediastinal aberrant goiter is extremely rare, characterized by independence from the thyroid gland. This tumor most commonly develops in the anterior mediastinum and should be differentiated from a thymoma. Moreover, as mediastinal aberrant goiters frequently have a blood supply arising from the thoracic great vessels, preoperative diagnosis and evaluation of the feeding vessel are vital for safe surgery. Herein, we report a rare case of mediastinal aberrant goiter characterized by high radiodensity on non-enhanced computed tomography (CT).Case presentationA 77-year-old woman underwent non-enhanced CT, which showed a 2.2-cm, well-circumscribed, homogeneous anterior mediastinal nodule with high radiodensity. The CT attenuation value of the nodule was as high as 91.9 Hounsfield units. A thymoma or mediastinal goiter was suspected owing to the tumor location and the lack of a cystic component. We performed anterior mediastinal tumor resection using video-assisted thoracoscopic surgery. Pathologically, variably sized follicles, indicative of thyroid tissue, were observed with hemorrhage and hemosiderin deposition. Moreover, papillary projections of small follicles (Sanderson’s polsters) were scattered without atypia of the follicular epithelium, indicative of an adenomatous goiter. The diagnosis of a mediastinal aberrant goiter was supported by the absence of an anatomical connection with the thyroid gland. The postoperative course was uneventful, and the patient was discharged on postoperative day 5.ConclusionThe thyroid gland has a high radiodensity on non-enhanced CT, which correlates with iodine concentration. This radiological feature may be useful for the preoperative differentiation of mediastinal aberrant goiters containing thyroid tissue.

Mediastinal lesions : The most common pathologies in chest X-rays and their correlations in computed tomography

Many pathologies of the mediastinum can be diagnosed using standard radiographs. Correlation of radiographic findings with computed tomography (CT) is instructive for abetter understanding and can help improve detection rates of mediastinal lesions. To identify the most common mediastinal lesions and to correlate their features in chest radiographs and CT. The International Thymic Malignancy Interest Group (ITMIG) classification in the anterior, middle, and posterior mediastinum is based on anatomic landmarks. Used as atool to characterize mediastinal lesions this classification is applied in this article. The most common lesions include mediastinal goiter, germ cell and thymic neoplasms in the anterior mediastinum, lymphadenopathy in the middle mediastinum, and neurogenic neoplasms in the posterior mediastinum. Other lesions of neoplastic or non-neoplastic origin can be distinguished in the three compartments and should be considered in the differential diagnosis. Knowledge of the most common pathologies in the three mediastinal compartments can accelerate differential diagnosis. Understanding the normal mediastinal lines is key in anatomic localization and detection of many lesions in chest radiographs.

Ectopic thyroid nodes in the mediastinum - report of two cases

Introduction. Ectopic thyroid is a rare anomaly characterized by presence of thyroid tissue outside its normal location, which could be the consequence of developmental abnormality, sequestration of thyroid nodes from nodal thyroid goiter or mechanical implantation of thyroid tissue after resection or trauma. Ectopic thyroid is commonly incidentally detected and causes differential diagnostic dilemma towards the neck and mediastinal tumors. The object of this report was to present two types of ectopic thyroid nodes located in the upper mediastinum, incidentally discovered by computed tomography (CT). Outline of cases. A hyperdense nodular lesion was found in the anterior upper mediastinum in a 42-yearold woman with adenocarcinoma of the esophagogastric junction in whom CT was performed due to staging purposes. Metastatic left supraclavicular lymph node was considered in the differential diagnosis. However, as the node was located in front of the neck fascia and just below the thyroid gland and showed similar density to thyroid tissue, the diagnosis of accessory thyroid gland was made, which was later confirmed by multiple repeated CT scans during the two-year follow-up period. In a 52-year-old woman presenting with intermittent chest pain and cough, contrast-enhanced CT scan revealed nodal thyroid goiter and three nodes of similar CT texture, located in the upper mediastinum, below the thyroid gland. Accordingly, the diagnosis of parasitic mediastinal goiter thyroid nodes was made. Conclusion. Ectopic thyroid nodes are presented by CT as well-circumscribed nodes of the same density as the thyroid gland, typically located anteriorly in the upper mediastinum.

Peculiarities of surgical treatment of cervico-mediastinal goiter

Objective. To analyze a surgical tactics and a component of operative interventions, performed for goiter of cervico-mediastinal localization; to formulate the operative technique peculiarities, which give positive effect.&#x0D; Materials and methods. Into the investigation the materials of clinical work in 2005 - 2019 yrs were incorporated of Department of Surgery No 2 of the Second Municipal Clinical Hospital of Poltava City, which constitutes a base of the Department of Surgery No 1 of Ukrainian Medical Stomatological Academy. There were analyzed the results of surgical treatment of 530 patients, suffering various forms of goiter.&#x0D; Results. Basing on data of complex clinic-instrumental and cytological investigations several tactically different operative interventions were performed, the content of which was directly dependent on anatomic peculiarities present. In 155 patients a cervico-mediastinal goiter was present.&#x0D; Conclusion. In big mediastinal goiter a severe operative situation occurs, necessitating nonstandard surgical decisions making. That is why the neck surgical access of the authors own in accordance to Kocher method was proposed. Extrafascial procedures may prevent some iatrogenic complications.

Utility and Safety of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Diagnosis of Isolated Mediastinal Masses.

BackgroundEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a valuable tool for diagnosing pulmonary disease due to its efficiency and safety. We retrospectively analyzed patients with mediastinal masses who underwent diagnostic EBUS-TBNA at Shanghai Chest Hospital, and evaluated the clinical accuracy of EBUS-TBNA in the diagnosis mediastinal masses.MethodFrom 2009 and 2014, patients who received EBUS-TBNA to diagnose a isolated mediastinal mass were enrolled. Clinical follow-up was performed to ascertain the patient’s final diagnosis.ResultsForty-six patients were enrolled in this study. Thirty-seven were diagnosed with an oncologic disease, 3 were diagnosed with a mediastinal infection, and 2 were found to have a mediastinal goiter. The overall sensitivity, specificity, positive predictive value, negative predictive value, diagnostic yield was 63.6%, 100%, 100%, 42.9%, and 71.4%, respectively.ConclusionEBUS-TBNA is a safe and effective means of diagnosing mediastinal masses.

Mediastinal Goiter Operated as Trans Clavicular Access as Adjunct to Cervical Incision

There are cases in which resection of cervico-mediastinal goitres requires additional thoracic access as an adjunct to standard transverse cervicotomy, and typically this takes the form of sternotomy or thoracotomy. The authors propose transclavicular access as an alternative to thoracotomy or sternotomy access for the removal of such goitres. This technical variant is performed by means of resection of the middle third of the clavicle and extraperiosteal disarticulation. They report a case of cervico mediastinal or “plunged” goitre associated with mediastinal metastasis from a follicular thyroid carcinoma in a 77-year-old woman, in whom this technical variant was used. They conclude by stressing the greater effectiveness, ease of execution and relatively limited “aggressiveness” of the technique in comparison with other ways of reaching the mediastinum. The variant proves effective in solving a number of technical, functional and aesthetic problems.

Voluminous primary mediastinal multinodular goiter as a rare cause of hyperthyroidism.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Superior mediastinal paraganglioma initially suspected of being a mediastinal thyroid goiter

Paraganglioma is a rare tumor arising from paraganglia. Few reports have described paragangliomas in the superior mediastinum. We report a case of superior mediastinal paraganglioma treated in our department. A 28-year-old woman visited our department because of suspected mediastinal tumor during a medical checkup. Contrast-enhanced CT showed a 39 × 35 × 65-mm tumor with a well-defined border extending from the lower pole of the left thyroid gland to the superior mediastinum. Laboratory tests showed no evidence of catecholamine overproduction. Mediastinal thyroid goiter was the most suspected preoperative diagnosis. We decided to perform a transcervical excision for both diagnosis and treatment. The tumor was easily detached from the lower pole of the left thyroid gland and was not continuous. The tumor capsule was brittle and bled easily. The operating time was 3 h and 11 min, and the amount of bleeding was 571 mL. The pathological diagnosis was paraganglioma. Paragangliomas are characterized by abundant blood flow and are likely to result in a high intraoperative bleeding volume. In addition, if the tumor is functional, circulatory abnormalities can occur during the perioperative period. Accurate preoperative diagnoses are important, and the possibility that paragangliomas can develop in the superior mediastinum should be considered.

Large posterior mediastinal goiter post total cervical thyroidectomy: a case report

Thoracotomy approach is indicated for a complete and safe posterior mediastinal goitre removal. A 68 years old male was hospitalized due to a right mediastinal mass found in a chest X-ray and confirmed by computed tomography. The patient had undergone total cervical thyroidectomy thirty years ago. A computed tomography (CT) guided percutaneous needle biopsy of the mass revealed thyroid tissue. Subsequently, the mass was completely resected through a right posterolateral thoracotomy. The histopathology confirmed a large mediastinal goitre with no signs of malignancy. The patient had an uncomplicated recovery. We present a relatively rare case of a successful resection of a posterior mediastinal goitre, occurring thirty years post-total cervical thyroidectomy. We advocate lateral thoracotomy to achieve a broad operative field and enhance surgical safety.

The transmanubrial osteomuscular-sparing approach: a valuable adjunct to the head and neck surgical armamentarium.

To describe and popularize the transmanubrial osteomuscular-sparing approach (TOSA) outside its original thoracic surgical field of application, based on the consideration that it could be of interest for the management of a number of head and neck cases in both elective and emergent scenarios. The main advantages of TOSA compared with transclavicular techniques are its superb exposure of anatomic structures located at the level of the cervicothoracic junction, and superior postoperative aesthetic and functional outcomes. Recently, a number of studies have described the association of TOSA with other minimally invasive approaches, such as video-assisted thoracoscopic surgery and robotic hybrid approaches, with the aim of avoiding association of the transmanubrial route with anterior/posterior thoracotomies, or more extended surgeries, such as the trapdoor or hemiclamshell procedures. TOSA, even though originally conceived to reduce the morbidity ensuing from classic transclavicular approaches for management of Pancoast tumors, may well play an important role in a number of head and neck surgical conditions, including those related to mediastinal goiter and thyroid cancer, management of stenosis and lesions of the thoracic trachea and esophagus, treatment of the junction between innominate, internal jugular, and subclavian veins, epiaortic arteries, thoracic duct, brachial plexus, and low sympathetic chain. Whenever comprehensive control of vascular and nonvascular structures of the upper mediastinal inlet is required, TOSA should be planned and performed by combining the expertise of cooperating professionals.

Predictive parameters of difficult intubation in thyroid surgery: a meta-analysis.

Airway management is a fundamental goal for the anesthesiologist. The rate of difficult laryngoscopy in patients undergoing thyroid surgery ranges from 6.8% to 9.6%. An accurate and detailed preoperative evaluation of the airway seems to be a promising tool to predict a potentially difficult airway management. We aimed to identify possible risk factors and physical findings that predict difficult intubation in thyroid surgery. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were analyzed, and the reference lists from the retrieved articles and previous reviews were searched for additional studies. Difficult intubation was defined as Cormack and Lehane grade ≥3 or Intubation Difficulty Scale score >5 by direct laryngoscopy. Studies that used advanced airway devices or ultrasound-based airway management were excluded. Gender, Mallampati Score, interincisor gap, thyromental distance, body mass index, tracheal deviation, histology, mediastinal goiter, mandibular protrusion, neck circumference and neck movement were evaluated. Qualitative analysis has been conducted in case of insufficient data for an appropriate meta-analysis. Eight studies that evaluated the accuracy of clinical findings for identifying difficult intubation in thyroid patients were reviewed (5853 patients). Two authors independently screened articles, extracted data and assessed risk of bias. 7.21% [95% CI: 6.57-7.91%] of patients undergoing thyroid surgery were difficult to intubate. The physical examination findings that best predicted a difficult intubation included Mallampati Score ≥3 (positive odds ratio 4.75 [95% CI: 2.22-10.12]); shorter thyromental distance thresholds ranging from <6.5-<6 cm; OR 3.64 [95% CI: 1.9-7.01]); 'low' interincisor gap, defined as a critical distance between incisors (ranging from <3.5 - <4.4 cm; odds ratio 2.57 [95% CI: 1.83-3.62]); presence of tracheal deviation (positive odds ratio, 2.06 [95% CI: 1.58-2.69]); Body Mass Index >30 kg/m2 (odds ratio 1.95 [95% CI: 1.20-3.15]) and males (odds ratio 1.54 [95% CI: 1.21-1.95]). Histological examination positive for cancer didn't increase the risk for difficult intubation. For mediastinal goiter, mandibular protrusion, neck circumference and neck mobility only a qualitative analysis was performed. In thyroid patients, the presence of high Mallampati Score, shorter thyromental distance, interincisor gap, tracheal deviation (the unique thyroid pathology linked parameter), obesity and male gender were risk factors for difficult intubation. However, all these significant parameters should be used in preoperative assessment to anticipate difficult intubation in thyroid surgery.