Retrosternal Goiter Research Articles

Cervical compression due to benign thyroid disorders is not associated with increased postoperative morbidity

Compressive symptoms due to malignant thyroid disorders and retrosternal goiter have been shown to be associated with increased perioperative morbidity. However, little is known about the risk associated with the surgical management of patients presenting with cervical compressive symptoms secondary to benign thyroid disorders. A retrospective review of data of patients undergoing thyroid surgery in a tertiary referral center was performed. The outcomes of patients with compressive symptoms due to benign thyroid disorders were compared to those of patients without compressive symptoms. 886 patients operated upon between 2005 and 2012 were included for analysis. 284 cases with compressive symptoms (study group) were compared to 602 cases without compressive symptoms (control group). There was no difference in the duration of surgery among both groups (123 vs. 126 min, p = 0.75). There was no significant difference among both groups with regard to postoperative hypocalcemia (1.4 vs. 1.1 %), rate of recurrent laryngeal nerve palsy (6.3 vs. 7.2 %) and postoperative bleeding (2.1 vs. 3.1 %). Compressive symptoms resolved in a significant number of patients following surgery. There was no significant difference in postoperative outcome between patients with and without compressive symptoms. Therefore, cervical compression due to benign thyroid disorders is not associated with increased perioperative morbidity.

Retrosternal Thyroid Goiter: Recurrent Laryngeal Nerve Dissection According to the Charles Proye's Toboggan Technique

Introduction: We present a case report supported by a video of a case of recurrent retrosternal thyroid goiter with superior identification of the recurrent laryngeal nerve (also called the Charles Proye's toboggan technique).1 Materials and Methods: In November 2012, we operated a 71-year-old patient for a recurrent unilateral retrosternal thyroid goiter. The patient underwent a subtotal thyroidectomy 20 years earlier; she showed symptoms of airway and esophageal compression. After a CT scan and a laryngoscopy, the patient underwent a right thyroid lobectomy. The surgery of retrosternal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion.2 Charles Proye described a surgical technique to avoid this lesion. To have a better exposition, a section of the prethyroid muscles can be considered, particularly if it is a voluminous and/or recurrent goiter.3–4 The approach starts with the thyroid isthmus liberation that is dissected free from the anterior part of the trachea and transected. Then, the middle thyroid vein is divided and the superior pole vessels are divided. The superior pole is then mobilized laterally, and the recurrent laryngeal nerve is searched for at its entry point into the larynx. The nerve function can be verified by the neuromonitoring, which also helps to find it in this vessel-rich area. The dissection continues between the nerve and the posterior part of the thyroid, progressively from top to bottom, descending as on a toboggan. After the recurrent nerve dissection, the goiter can usually be extracted without difficulty, dividing the last vessels holding the goiter inside.1–4 Results: With the toboggan technique, it is often possible to do the thyroidectomy for mediastinal goiter without sternotomy and recurrent nerve damage.1 Using this technique, the recurrent nerve is never put under tension. The patient operated with this technique had a duration of hospitalization of 3 days without any postoperative complication. Conclusions: Whenever possible, we prefer to operate intrathoracic goiters using this technique because it allows us to better recognize and preserve the recurrent nerve without putting it under tension. The Source of Work or Study: In 1981, Charles Proye described a new surgical technique to operate intrathoracic goiters without sternotomy and with preservation of recurrent nerve; the surgery of mediastinal goiter is at increased risk for iatrogenic recurrent laryngeal nerve lesion. We utilize in our clinic this technique for intrathoracic goiters. This video describes the details of the Charles Proye's technique. The authors have not received any payment or support. The article is based on a videocommunication during the congress of the IAES in Helsinki, August 2013. Running time of video: 4 mins, 53 secs

Thoracoscopy: beyond the key hole

Background Lateral thoracotomy or median sternotomy causes significant morbidity. Thoracoscopy reduces the morbidity of the incision and provides a clear and magnified display of anatomy. It involves a learning curve. Objectives To evaluate the safety, efficacy and advantages of thoracoscopy. Method A retrospective analysis of 67 thoracoscopic procedures performed at the university surgical unit, Teaching Hospital, Peradeniya. Results The total number of 67 procedures included thymectomy, lymph node biopsy, lymph node dissection, excision of retrosternal goitre, sympathectomy, splanchnicectomy, oesophagectomy, lung biopsy and diagnostic procedures. The time taken was acceptable with minimum blood loss and selective use of intercostal drainage. There were no conversions. Intensive care was needed only for oesophagectomy, thymectomy and excision of retrosternal goiter. The need for narcotic analgesics was minimal. Feeding, mobilization and discharge from hospital were early except after oesophagectomy. There was a mortality of 13% in the oesophagectomy group. No morbidity or mortality was recorded among others. Conclusion Thoracoscopy permitted a wide range of surgeries to be done safely with reduced morbidity. DOI: http://dx.doi.org/10.4038/sljs.v32i1.6869 The Sri Lanka Journal of Surgery 2014; 32(1): 29-34

Surgical Management of Retrosternal Goitre: Experience of a Moroccan Center

Introduction and objectivesThis was a retrospective study reviewing 93 cases of retrosternal goitre (RG) operated in our department, with the aim of describing epidemiological and clinical data and discussing the surgical challenges of RG. Patients and methodsFrom January 2004 to December 2012, 35 men and 58 women presenting with RG had surgery. Eighty-nine cases (95.7%) underwent cervicotomy, and a sternotomy was mandatory in 4 cases (4.3%). Laryngoscopy was performed in all cases. A second preoperative laryngoscopy by a senior was mandatory for patients with hoarseness or dyspnea even if the initial laryngeal exam was normal. ResultsA cervical mass was noted in 81 cases (87.1%), dyspnea in 17 cases (18.3%), dysphagia in 2 cases (2.1%), hoarseness in 7 cases (7.5%), partial vena cava syndrome in 2 cases and recurrent goitre was noted in 2 cases (2.1%) after previous thyroid resection. Mediastinal extension was on the left side in 47 cases (50.5%), on the right side in 29 cases (31.2%) and bilateral in 17 cases (18.3%).A total thyroidectomy was performed in 86 cases (92.5%) and a unilateral isthmo-lobectomy was performed in 7 cases (7.5%). Mean goitre size was 9.3cm. Postoperative complications were present in 9 cases (9.7%), 3 cases with hypoparathyroidism (3.2%) and 4 cases (4.3%) of recurrent nerve injury. There was no postoperative death. The histological study objectified 88 cases of multiheteronodular goitre, 4 cases of Basedow thyroid, and 1 case of thyroid carcinoma (papillary carcinoma). ConclusionOur experience confirms that cervicotomy often allows removing goitre with a mediastinal extension. However, intraoperative enlargement may be necessary, with increased operating time, hospital stay and morbidity.

Should asymptomatic retrosternal goitre be left untreated? A prospective single-centre study.

Retrosternal goiter may cause symptoms of airway obstruction and dysphagia, but often it is asymptomatic and is increasingly detected incidentally with imaging investigations. Consensus has been reached that sternotomy is not necessary in most cases, as a collar incision normally suffices. Yet, surgery for retrosternal goiter is associated with more complications than cervical goiter. There is controversy over whether patients with asymptomatic retrosternal goiter should be operated. Proponents argue that retrosternal goiter may be a risk for thyroid cancer and may progress to later cause symptoms, although clear evidence is missing. Between 1984 and 2012, 132 patients underwent surgery for benign retrosternal goiter. Preoperatively, the benign nature was clinically apparent and confirmed by fine needle cytology in most cases. Sternotomy was required in only 4 of the 132 operations. Three patients died in the postoperative period. The risk of morbidity and mortality was 16.7% in 60 patients with compression symptoms and 13.9% in 72 patients without compression symptoms (P = 0.808). Histology revealed no case of unsuspected cancer. Surgery for retrosternal goiters involves a higher risk for complications than do cervical goiters, and the risk does not differ between patients with and without symptoms. This, and the fact that no patient in this study had unsuspected cancer, calls into question the rationale for surgery in patients with asymptomatic retrosternal goiter without suspected cancer.

Tratamiento quirúrgico del bocio retroesternal: experiencia en un centro de Marruecos

Introduction and objectivesThis was a retrospective study reviewing 93 cases of retrosternal goitre (RG) operated in our department, with the aim of describing epidemiological and clinical data and discussing the surgical challenges of RG. Patients and methodsFrom January 2004 to December 2012, 35 men and 58 women presenting with RG had surgery. Eighty-nine cases (95.7%) underwent cervicotomy, and a sternotomy was mandatory in 4 cases (4.3%). Laryngoscopy was performed in all cases. A second preoperative laryngoscopy by a senior was mandatory for patients with hoarseness or dyspnea even if the initial laryngeal exam was normal. ResultsA cervical mass was noted in 81 cases (87.1%), dyspnea in 17 cases (18.3%), dysphagia in 2 cases (2.1%), hoarseness in 7 cases (7.5%), partial vena cava syndrome in 2 cases and recurrent goitre was noted in 2 cases (2.1%) after previous thyroid resection. Mediastinal extension was on the left side in 47 cases (50.5%), on the right side in 29 cases (31.2%) and bilateral in 17 cases (18.3%).A total thyroidectomy was performed in 86 cases (92.5%) and a unilateral isthmo-lobectomy was performed in 7 cases (7.5%). Mean goitre size was 9.3 cm. Postoperative complications were present in 9 cases (9.7%), 3 cases with hypoparathyroidism (3.2%) and 4 cases (4.3%) of recurrent nerve injury. There was no postoperative death. The histological study objectified 88 cases of multiheteronodular goitre, 4 cases of Basedow thyroid, and 1 case of thyroid carcinoma (papillary carcinoma). ConclusionOur experience confirms that cervicotomy often allows removing goitre with a mediastinal extension. However, intraoperative enlargement may be necessary, with increased operating time, hospital stay and morbidity.

Is it possible to predict the need for sternotomy in patients undergoing thyroidectomy with retrosternal extension?: Table 1:

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'in patients undergoing thyroidectomy for retrosternal goitre, what factors predict sternotomy?' Altogether 165 papers were found as a result of the reported search, of which only 3 prospective studies, 1 review paper and 2 retrospective studies represented the best evidence to answer the clinical question. The authors, journals, date and country of publication, patient group studied, study type, relevant outcomes and results of the papers are tabulated. We conclude that a combination of preoperative clinical and radiological risk factors, alongside informed patient choice can be used to predict the need for sternotomy in thyroidectomy for goitre with retrosternal extension. Clinically, a history of goitre with retrosternal extension beyond 160 months is a risk factor for sternotomy. Thyroid tissue density, posterior mediastinal location and subcarinal extension, as measured using computed tomography (CT) imaging, are independent preoperatively obtained risk factors for sternotomy, which are supported by both prospective and retrospective studies. Thyroid tissue density is the strongest factor and increases the risk of sternotomy 47-fold. Minimal upper sternotomy (sternal-split) can be used instead of median sternotomy where there is evidence of retrosternal extension to the aortic root. CT evidence of an ectopic nodule, a dumbbell-shaped goitre, a conical-shaped goitre constricted by an isthmic thoracic inlet or a thoracic goitre component wider than the thoracic inlet can also predict the need to undergo sternotomy. Finally, informed consent should include a discussion that patients with bilateral multinodular goitre and evidence of intrathoracic extension, who are undergoing total thyroidectomy via cervicotomy, have an independently increased risk of complications, specifically recurrent laryngeal nerve injury. After explanation of these risks, a patient may be unwilling to accept the increased risks of cervicotomy per se versus those of combined cervicotomy and sternotomy.

Multinodular goiter with retrosternal extension causing airway obstruction: Management in intensive care unit and operating room.

Sir, Airway compromise and difficult intubation may be anticipated in huge thyroid with gross tracheal deviation. Retrosternal extension can present with compression of structures below it and may mimic a medical condition or as emergency respiratory obstruction. Benign goiters affect 5% of the general population in nonendemic areas and 15% in endemic areas, and of these 1-15% of all patients undergoing thyroidectomy have a retrosternal goiter.[1,2] A 58-year-old female, with thyroid swelling presented with sudden onset of dyspnea, noisy breathing, and cough with expectoration for 5 days. She was provisionally diagnosed and treated for chronic obstructive pulmonary diseases. She had expiratory wheeze with respiratory distress, bilateral crepitations, rhonchi, with saturation of 85 with oxygen by the mask of 5 L/min, pulse rate of 150 beats/min. She required immediate intubation and respiratory support, Intubated with injection propofol and injection suxamethonium without difficulty. The lobes of the thyroid gland were diffusely palpable and nodular. Lower pole of thyroid swelling was not palpable. Investigations showed hematocrit 27; white blood cells of 17.700/mm3, thyroid function tests-free T3 0.59 ng/ml, free T4 2.13 mcg/ml, thyroid stimulating hormone 1.25 IU/ml. Lateral view of neck X-ray showed compression of the trachea [Figure 1] and anteroposteior view showed deviation of the trachea to left. Figure 1 Lateral view X-ray showing compression of trachea Fiberoptic flexible bronchoscope passed through the endotracheal tube (ETT) showed edema and congestion of luminal wall, side-to-side narrowing and intraluminal bulge at the level of thyroid. On computed tomography scan severely narrowed trachea from C6 to D2 with narrowest part at D2 measuring 6 mm and extension of left thyroid gland retrosternally just above the arch of aorta [Figure 2]. Figure 2 Computed tomography showing thyroid gland just above on the arch of aorta She was planned for elective thyroid surgery, after obtaining informed consent, injection glycopyrollate as premedication, induced with propofol, maintained with fentanyl, oxygen, nitrous oxide, isoflurane. ETT was changed to reinforced tube threaded over bougie, during this process patient was breathing spontaneously and had inspiratory stridor as we were exchanging the tube. Intra operative period was uneventful and thyroid gland extending up to arch of aorta. Muscle relaxation maintained with vecuronium and vitals monitored. Post procedure she returned to intensive care for observation for 5 days, flexible intubating fiberoptic scope was introduced into the trachea through ETT, tracheal rings were inspected after withdrawal of ETT up to cricoids cartilage. The integrity of the cartilages checked by mechanical compression of tracheal rings by the surgeon and observing through the fiber optic scope for the recoil to the original shape. Extubation done confirming there was no collapse of lumen, no stridor or respiratory distress. Upper airway obstruction due to thyroid gland has been reported up to 31% and difficulty in intubation has been reported 11%.[3,4] Central airway obstruction produces symptoms of dyspnea, stridor, or obstructive pneumonia and is often misdiagnosed as asthma. Meticulous planning for managing difficult airway and perioperative care in planned extubation after confirming the absence of airway compromise is of prime importance. Difficult airway algorithms and experience of the anesthesiologist plays a major role in management and outcome of the procedure. The early identification of all probable outcomes and prompt mobilization of resources allowed a favorable outcome in this case.

Chylothorax Following Thyroid Surgery: A Report of two Cases and Review of Management Strategies

ABSTRACT Chylothorax is a rare complication following thyroid surgery. Management of this complication can be conservative or surgical. We report two cases of chylothorax following excision of retrosternal goiter and neck dissection. The relevant literature is reviewed regarding the management strategy, highlighting the importance of surgical anatomy. How to cite this article Nalukurthi SC, Kishore J, Samarasam I, Gnanamuthu BR, Paul Mj. Chylothorax Following Thyroid Surgery: A Report of two Cases and Review of Management Strategies. World J Endoc Surg 2014;6(3):115-118.

A primary retrosternal goiter successfully managed via a cervical approach

A primary retrosternal goiter successfully managed via a cervical approach

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.

Floating left innominate vein neoplastic thrombus: A rare case of mediastinal extension of follicular thyroid carcinoma

We report a case of advanced follicular thyroid cancer with innominate vein involvement. To our knowledge, this seems to be the first case treated in emergency surgery, reported in literature. A 59-year-old woman with a five-year history of a large and mainly right-sided cervical mass presented with dyspnea, unilateral arm swelling, facial flushing, and venous congestion. An emergency computed tomography scan revealed a thyroid mass extending into the upper mediastinum with displacement and compression of the right jugular vein and carotid artery and apparent adherence to the superior vena cava and left innominate vein. An emergency total thyroidectomy was performed by means of a sternotomy. The lower portion of the retrosternal goiter projected directly into the left innominate vein, with tumor floating in its lumen. Removal of the neoplastic thrombus was performed, through an incision in the vein, en bloc with the thyroid mass. Both goiter and thrombus were completely replaced by follicular carcinoma. Accurate preoperative assessment through contrast-enhanced computed tomography is strongly suggested in the presence of enlarged thyroid gland extending into the mediastinum whenever angioinvasion is suspected. This could prevent blinded maneuvers such as digital externalization of the thoracic component of the gland, which can be fatal in cases of cervico-mediastinal goiter extending into great cervical or mediastinal veins.

The calcium–phosphate balance, modulation of thyroid autoimmune processes and other adverse effects connected with thyroid arterial embolization

In search of new treatment options for thyroid diseases, when conventional procedures are ineffective, contraindicated or associated with serious side effects, safety of thyroid arteries embolization in the treatment of particular thyroid diseases was evaluated. The study included eight subjects with retrosternal toxic goiter, six patients affected by Graves’ disease, five cases of retrosternal non-toxic goiter, two subjects with post-amiodarone hyperthyroidism, and one patient with severe thyroid-related orbitopathy, who underwent selective embolization of thyroid arteries. The study assessed and compared calcium–phosphate balance, modulation of thyroid autoimmunity and the presence of different side effects in patients who underwent the procedure. In addition, the serum concentrations of thyroid hormones, anti-thyroid autoantibodies and thyroid volume have been measured. Five of all enrolled subjects (22.7 %) experienced transient, not clinically relevant hypocalcaemia with no need for calcium supplementation. There were no significant changes in serum calcium levels in patients after embolization of both inferior thyroid arteries. The transient side effects associated with the treatment were neck pain and a slight increase in body temperature. Noted high concentration of free thyroid hormones immediately after the procedure was not accompanied by worsening of symptoms or signs of thyrotoxicosis. In patients with Graves’ disease, a significant decrease in thyrotropin receptor antibodies level was observed. Thyroid arterial embolization does not disturb permanently calcium–phosphate balance, modulates positively thyroid autoimmune processes and is associated with no serious post-procedure side effects. Hence, it may be considered as a safe and effective treatment modality for selected thyroid disorders.

Resection of Huge Retrosternal Goiter Through a Novel Combined Cervical and Robot‐Assisted Approach

A 53-year-old man was referred to our department with a history of cough, especially at night, for 3 months. He was found to have a huge retrosternal goiter. We applied a novel combined cervical and robot-assisted approach to resect this difficult goiter. Using the da Vinci robot system, the intrathoracic part of the goiter was dissected and mobilized completely from the mediastinum to the inlet of the thorax. The dissected part of the goiter was left in the thorax. A right cervical half-collar incision about 6 cm was then performed. The goiter was finally removed from the neck incision. Histopathologic examination reported a multinodular goiter. By the method shown in the case, resection of huge retrosternal goiters through a combined cervical and robot-assisted approach is feasible and safe. This method provides an alternative option to the more invasive traditional approaches.

Case report of undiagnosed retrosternal goitre – an unpleasant finding during complex cardiac surgery procedure

An 84-years old patient was scheduled for elective, combined procedure of aortic valve replacement and coronary artery bypass grafting. After median sternotomy was done, there was a finding of unusual retrosternal mass. Concurrently, otherwise routine procedure, changed it course. During surgical manipulation, patient started to show signs of thyreotoxic crisis. Patient was initially stabilised with intravenous metoprolol and amiodarone, blood was taken for analysis and we decided to continue with planned procedure. Bioprosthesis and vein graft on PD were implanted. During operation , blood analysis came through and revealed high levels of FT4 – free thyroxin : 44,10 pmol/L (with normal values of 11,5 – 22,7 pmol/L). After CPB termination and adequate hemostasis, with help of general surgeon, partial thyreoidectomy was done. In early postoperative course, patient recived some inotropic support and was extubated on 4th postoperative day. Except for some minor restlessness, recovery went uneventfull and 84 years old patient was released in good health, on 18th postoperative day. Upon release, patient was reffered to endocrinologist for further treatment.

Neglected Retrosternal Goitre: A management Dilemma

Mediastinal goiters were first described by Albrecht von Haller in 1749, as the extension of the thyroid tissue below the upper opening of the chest.1 As goiters grow they attain a mediastinal position by extending through the thoracic inlet. As these mediastinal goiters grow very slowly and are present over many years, they often go unrecognized either because the thyroid mass is managed conservatively by suppressive therapy or the compressive symptoms misinterpreted as cardiopulmonary symptoms, leading to the late diagnosis or even misdiagnosis. Here lies the importance of taking a detailed history, carrying out a thorough clinical and investigative evaluation and maintaining an open mind. Advancing age is associated with increased medical co-morbidity, implying that operation at an earlier stage of goitre development may be associated with reduced complications related to co-existing disease. Here, we report an interesting case of 37 year old female with neglected retrosternal goitre.

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.

Unexpected Aetiology in Elderly Patient Presenting with Acute Hypercapnic Coma

In an emergency room setting, hypercapnic respiratory failure is a clinical entity infrequently encountered. It results from inadequate removal of carbon dioxide from distal alveoli. Goitre is defined as abnormal enlargement of the thyroid gland. It may cause compression of surrounding structures including trachea as thyroid dimension increases. Goitre associated with breathing difficulty is a very well-known situation. Retrosternal goitre can be misinterpreted as asthma and can lead to diagnostic delay. We report a case in which the patient with retrosternal goitre presented rarely with acute hypercapnic coma.

P-201EXTENDED TRANSCERVIVAL APPROACH WITH ELEVATION OF THE STERNUM FOR RESECTION OF THE THYROID CANCER METASTATIC NODES AFTER PREVIOUS THYROIDECTOMY: ANALYSIS OF THE LARGEST REPORTED SERIES

Objectives: Analysis of the operative technique and the results of the minimally invasive transcervical approach for resection of the mediastinal metastatic lymph nodes of the thyroid cancer. Methods: Clinical diagnosis of the metastatic spread to the mediastinal nodes was based on the elevated thyreoglobulin (Tg) level for papillary and follicular cancer, elevated calcitonin (Ct) level for medullary cancer and on visualization of the suspicious nodules on the imaging studies (CT, PET/CT, scintigraphy). The patients with retrosternal goiter and ectopic mediastinal goiter were excluded. Operative technique included elevation of the sternum with a hook connected to special frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland) which widened the access to the mediastinum. The mediastinal nodes were resected en-bloc with the surrounding fatty tissue. The dissection was guided by the previous imaging studies. Results: Overall, there were 94 patients operated on in the period from 1 July 2007 to 31 December 2012. In 5 patients (5.3%) concomitant thyroidectomy was performed. Re-resection of the recurrent metastases was performed in 7 patients. In 43 patients there was single mediastinal nodal station involved and in 51 patients there were multiple (2-5) nodal stations involved. Resection was incomplete in 5 patients (5.3%). Conversion to sternotomy/thoracotomy was necessary in 3 patients (3.2%). In 5 patients (5.3%) concomitant partial sternectomy was performed for sternal metastasis. There was no mortality and 8.9% morbidity. Conclusions: Analysis of this largest reported series of the mediastinal metastases of the thyroid cancer showed that transcervical approach with elevation of the sternum enabled minimally invasive, safe and effective resection with sternotomy or thoracotomy avoided in almost all patients. Detailed imaging studies of chest should be a standard of preoperative evaluation of patients with thyroid cancer. Disclosure: All authors have declared no conflicts of interest. Interactive CardioVascular and Thoracic Surgery

Critical Airway Obstruction by Mediastinal Masses in the Intensive Care Unit

Critical airway obstruction is a dreaded complication of a mediastinal mass. The acute management is difficult and catastrophic outcomes have been reported. A total of 19 patients, aged between 13 and 69 years, who had critical major airway obstruction due to mediastinal mass requiring mechanical ventilation were reviewed. Three patients had benign pathologies (retrosternal goitre, bronchogenic cyst, giant left atrium) and three had lymphoma. The remaining patients had advanced malignancies: metastatic mediastinal lymphadenopathy (n=6), thyroid carcinoma (n=1) and oesophageal carcinoma (n=6). Three patients underwent surgery, three received chemotherapy and 15 had airway stenting under deep intravenous sedation. Apart from one patient who had brain haemorrhage and nosocomial infection after cardiac surgery, all other patients were successfully weaned off ventilation within five days after the interventions to alleviate the major airway obstruction without major complications. All patients were discharged from hospital without supplemental oxygen. Patients who had benign pathologies and lymphoma (n=6, 32%) were still alive after a mean follow-up period of six years (range 3 to 10) and those with metastatic disease died after a mean survival period of 3.3 months (range 1 to 9). In summary, critical major airway obstruction is caused by a heterogeneous group of mediastinal pathologies, and the definitive treatment and long-term prognosis of these patients are highly dependent on the underlying aetiology. Combining various therapeutic modalities can lead to successful separation of these patients from mechanical ventilation within a short period of time.