Retrosternal Goiter Research Articles

Outcome of Thyroid Surgery without Drainage Tube- A Study of 60 Cases

Introduction: The use of a negative suction drainage tube in the neck in thyroid surgery is a common practice in order to avoid hematoma or seroma or other complication. It is associated with neck discomfort, post operative neck pain, delayed ambulation, longer hospital stay and ugly scar formation.
 Objective: To determine the advantages and safety of thyroid surgery without negative suction drainage tube.
 Materials and Methods: A cross-sectional observational study was carried out from September 2015 to May 2017 in the Department of Otolaryngology and Head-Neck Surgery, Kurmitola General Hospital, Dhaka Cantonment and Azmol and Life Aid General Hospital, Mirpur, Dhaka. A total of 60 patients who had undergone total thyroidectomy or hemithyroidectomy for thyroid disorders without drainage tube were included in this study. Patients with previous thyroid surgery, retrosternal goiter or malignant diseases of thyroid requiring neck dissection, undifferentiated thyroid cancer patients and those undergoing anticoagulant therapy were excluded from this study. Data were collected and recorded in a structured case report form. Data were processed and analyzed by the Statistical Package for Social Science (SPSS) version 20.
 Results: Hospital staying was shorter for 50 patients out of 60 and 83.34% patients were discharged on the 2nd postoperative day. The time of mobility of patient was shorter and 66.66% patients became ambulated from bed after 11-14 hours. Complication was less and only 11 patients developed different type of complications.
 Conclusion: Thyroid surgery can be done safely and perfectly without negative suction drainage tube in the neck with a shorter period of hospital stay, early ambulation, fewer complications and morbidities. However, the drain should be used in the presence of large dead space, particularly when there is a huge multinodular goiter or intrathoracic extension or when the patient is on anticoagulant or anti-platelet treatment.
 Journal of Armed Forces Medical College Bangladesh Vol.13(1) 2017: 62-65

Retrosternal goitre: the role of the thoracic surgeon.

Purpose of this Mini-Review is to evaluate the role of a thoracic surgeon in the surgical management of retrosternal goitre. A cervical approach is sufficient in the majority of the cases. On the other hand, there are cases where a cervical approach is combined with sternotomy or thoracotomy, depending on the position of the goitre, in the anterior or posterior mediastinum. On top of that, different minimally invasive approaches including video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery (RATS) have been introduced, providing faster recovery, superior manoeuvrability and better aesthetic results.

Retrosternal Goiter – Cancer Incidence

The retrosternal goiter is a rare thyroid gland disease, which mainly affects women over 60 years, characterized by increased thyroid size, weight and volume, which invades the thoracic cavity. Failure to perform the surgery has been recommended in some cases as an alternative way of improving the quality of life, especially in asymptomatic elderly patients. However, there is an incidence of cancer in retrosternal goiters associated with a higher rate of complications, justified the early surgical approach, especially in young patients, even if asymptomatic. This work results from a case report and literature review on retrosternal goiter and cancer incidence in a 62-year-old patient submitted total thyroidectomy with histopathologic findings after surgery, papillary carcinoma, follicular carcinoma and follicular adenoma. These findings alerts us to the possibility of cancer incidence in these patients, recommending in such cases, early surgical treatment

RETROSTERNAL GOITRES: A PRACTICAL CLASSIFICATION.

There is no standard definition for goitres extending below the thoracic inlet and no clear guidelines for pre-operative planning of surgery. The aim of this study is a practical classification of retrosternal goitres (RSG) based on the anatomical , radiological shape and size of the thyroid. Retrospective analysis of all thyroidectomies performed in a referral centre between January 2012 and December 2016. Patients with RSGs had a pre-operative CT scan of neck/thorax. Imaging was reviewed to establish features to predict the difficulty of delivering the goitre through the neck incision and to advise the best surgical approach. 847 thyroidectomies were performed with n=98 involving RSGs. TypeA (n=47) are RSG with a shape of a "cone" or pyramid with the apex pointing down. Cervicotomy is the usual approach. TypeB (n=39) are goitres with a shape of a "pyramid' with the apex pointing up, cervicotomy with ± manubriotomy or sternotomy ± thoracotomy maybe required. TypeC (n=6) are thyroid enlargements in the mediastinum connected by a pedicle with the thyroid in the neck. A cervical approach ± manubriotomy or sternotomy ± thoracotomy is needed. TypeD (n=6) are true intrathoracic or "forgotten" goitres. Sternotomy is indicated for thyroids in the anterior mediastinum though a thoracic approach for those located in the posterior mediastinum might be needed. The shape and size of goitres is important in carefully planning surgery. CT imaging with cross-sectional reconstruction should be analysed before operation. The proposed classification helps treatment planning and allows comparison of outcomes by anatomical complexity.

Airway Management in Patients with Tracheal Compression Undergoing Thyroidectomy: A Retrospective Analysis.

Background:Airway management in large and retrosternal goiters with tracheal compression is often fraught with challenges and is a source of apprehension among anesthesiologists globally.Aims:In this study we attempt to delineate the preferred techniques of airway management of such cases in our institution and also to assess whether airway management was unnecessarily complicated.Setting and Design:Retrospective analysis.Materials and Methods:A retrospective review was conducted of thyroidectomies performed in our institution over a three year period from January 2013. Clinical, radiological, pathological, anesthetic and surgical data were obtained from hospital case records.Statistical Analysis:Qualitative data is represented as frequencies and percentages and quantitative data as mean and standard deviation.Results:Of 1861 thyroidectomies tracheal compression were present in 50 patients with minimum tracheal diameter ranging from 4-12mm (mean 7.84); with majority(95%) having a benign pathology. Critical tracheal compression (≤5 mm) was observed in four patients. Conventional intravenous induction and intubation under muscle relaxant was performed in majority (64%) of these patients. The rest of the cases (n=18) were intubated while preserving spontaneous ventilation after induction. Primary technique of airway management was reported successful in all cases with no instances of difficult ventilation or intubation. Postoperative morbidity in few cases resulted from hematoma (n=1), recurrent laryngeal nerve palsy (n=1), tracheomalacia (n=1) and pulmonary complications (n=2).Conclusion:Airway management in patients with tracheal compression due to benign goiter is quite straightforward and can be managed in the conventional manner with little or no complications.

Primary retrosternal goiter mimicking as teratoma of anterior mediastinum: A diagnostic enigma

Primary intrathoracic goiters arising from aberrant thyroid tissue are rare, representing <1% of all retrosternal goiters (RGs). We report a rare case of primary RG in a male patient with symptoms of mediastinal mass lesion alone. By careful examination and with the help of radiological imaging, we could pick up a thyroid swelling with a mediastinal mass which led to a diagnostic dilemma, as the thyroid swelling was reported as a multinodular goiter and the mediastinal mass was misdiagnosed as teratoma. We subjected the patient to a functional imaging with a thyroid scintigraphy, which revealed a thyroid swelling with retrosternal extension that was managed by surgery (total thyroidectomy and mediastinal mass excision) with only a Kocher's neck crease incision.

Co-Existent Symptomatic Large Retrosternal Nontoxic Multinodular Goiter With Mediastinal Lipoma

ABSTRACT Objective: To present a rare case of a co-existing large retrosternal nontoxic multinodular goiter (MNG) and a large mediastinal lipoma in a woman with compressive symptoms. Methods: The clinical presentation and diagnostic utilization of computed tomography (CT) in the management of this case are presented. Results: A 66-year-old woman was evaluated for slowly progressive, intermittent dysphagia and neck pressure over a period of 4 years. The nodular thyroid gland had been biopsied in the past and noted to be benign. Examination of the thyroid showed a large nodular goiter with an estimated weight in excess of 100 g. Thyroid function tests were within normal limits. A chest radiograph showed a large soft tissue mass in the upper right anterior mediastinum and lower neck with displacement of the trachea to the left. A CT scan with intravenous contrast of the neck and chest showed that the mass was comprised of both a large MNG and a large adjacent fat density mass in the right anterior mediastinu...

Volumetric Analysis is Useful for Predicting Use of Sternotomy During Retrosternal Thyroidectomy

Surgical removal is the recommended treatment for retrosternal goitre. This can be successfully achieved through a cervical incision in most cases, however occasionally a thoracic approach is required. Being able to predict the need for sternotomy would improve logistical efficiency, saving time and money, and allow patients to be better informed preoperatively. The aim of this study was to determine whether analysing thyroid volume on preoperative CT scans could help predict the use of sternotomy. To the best of our knowledge this is the first study investigating this. A retrospective study was conducted on 64 patients who underwent thyroidectomy for retrosternal goitre at the Golden Jubilee National Hospital, Scotland, between 2012-2016. Patient demographic information and pathological reports were obtained from databases. Preoperative CT scans were used for volumetric analysis. The total volume, the volume inferior to the level of the sternal notch (intrathoracic volume), and the anteroposterior diameter of the thoracic inlet were measured. An index of relative goitre size was calculated by dividing intrathoracic volume by thoracic inlet diameter. Mann-Whitney U tests and Fisher’s exact tests were used to analyse continuous and categorical variables respectively. Goitres were successfully removed by a cervical incision alone in 55 patients, while thoracic intervention was needed in 9 cases (13.3%). Intrathoracic volume (p=0.0091) and volumetric index (p=0.0033) were significantly larger in those requiring sternotomy. Total volume was not significantly different. All other variables measured were similar in both groups. Our results suggest that assessing intrathoracic volume of goitre is useful in predicting the need for sternotomy. However, it is not able to completely rule out thoracic intervention. The volumetric index is likely to be a better predictor than volume alone.

Consequences of bleeding after thyroid surgery - analysis of 7805 operations performed in a single center.

IntroductionSurgical treatment of thyroid gland diseases is associated with the possibility of severe complications. The most dangerous of them is bleeding. Current studies focus on its risk factors, rather than reoperation-related consequences.Material and methodsWe analyzed 7805 thyroid operations performed from 1996 to 2014 in the Clinic of General, Gastroenterological and Endocrine Surgery of Wroclaw Medical University. Typical risk factors, symptoms and consequences of bleeding were analyzed.ResultsAmong operated patients 88.2% were female and 11.8% male. Bleeding occurred in 84 (1.08%) patients. Sex (p = 0.006), preoperative thyroid pathology (p = 0.03), and type of operation (p < 0.001) are significant risk factors for bleeding, while retrosternal goiter and surgeon’s experience are not. Risk of bleeding is highest in the case of male sex, toxic goiter and total resection of the thyroid gland. Most reoperations took place within 6 h. In 88.8% of cases of this kind of complication the surgeon indicated the exact source of bleeding; most commonly it was the neck muscles, skin and subcutaneous tissue, or the thyroid stump. Three patients required a second reoperation, 24 suffered further complications, and 8 required transfer to the Intensive Care Unit (ICU). Cardiac arrest occurred in 3 patients and 2 suffered bilateral vocal cord palsy.ConclusionsBleeding after thyroid operations is a direct life threat that requires immediate intervention. As a result death may occur, half of patients suffer other complications and some require intensive care. The risk is highest in the case of male sex, toxic goiter and total resection of the thyroid gland. Each patient after thyroid surgery needs to be closely observed. An operating theatre and ICU should be available at all times.

Anatomical approach to surgery for intrathoracic goiter.

The anatomical approach to the intrathoracic goiter (ITG) was used to understand its etiology and to rationalize surgical technique of thyroidectomy. For a retrospective chart review, we selected cases of multinodular goiter with totally ITGs (n=69; M 29, F 40), while 916 cases with cervical goiter were used for comparison. The topography of the thyroid gland was assessed against the tracheal rings and against the vertebrae. The regional anatomy of the thoracic inlet was assessed by its bony margins and the relations of structures traversing the area. Average tracheal-diameter-to-thoracic-inlet ratio was calculated. The ITG group consisted of 52 cases of retrosternal goiter (75.4%), nine cases of retrotracheal goiter (13%), and eight cases of retroesophageal goiter (11.6%). In all but one analyzed cases, the goiters were removed via cervical incision. Mean weight of goiters was 183g. The area of thoracic inlet in the cases of ITG had no difference in comparison with the cases of cervical goiter (F/M p=0.11/0.15), but the tracheal-diameter-to-thoracic-inlet ratio was significantly smaller (F/M p=0.06/0.04). In the ITG cases, the position of the upper edge of the isthmus of the thyroid was about 1.5 tracheal rings lower than in healthy individuals (p=0.03). The area of the thoracic inlet, the neck size, and the anteroposterior diameter of the inlet do not affect the development of the ITG. The smaller tracheal-diameter-to-thoracic-inlet ratio and the lower position of the thyroid gland are the main indicators for the development of the ITG.

Surgical tactics in thyroid tumors located in the posterior mediastinum

The article described a rare clinical case of retrosternal follicular thyroid cancer located in the posterior mediastinum. The tumor was 11 cm in diameter, originating from the lower section of the right thyroid lobe, descended down retrosternally, while bulging out the internal jugular vein and common carotid artery. The tumor descended in the posterior mediastinum, from behind the subclavian artery and vein, adjoining posterior - to the back of the esophagus, medial – to the trachea, anterior - to the superior vena cava, and bordered the lower arc of the subclavian vein, inferior right - to the right main bronchus, and caused compression of structures described above. With such a location of the tumor and its size performing surgery by cervical access poses serious technical difficulties, while sternotomy does not fully ensure adequate and secure access to the posterior mediastinal tumor. Therefore, the most efficient access in the case of retrosternal goiter located in the posterior mediastinum would be the combination of thoracotomy in the fifth intercostal space with cervical access via the front of the neck.

The study of normal parathyroid echogenicity

Background: Some of the normal parathyroid can be shown on an ultrasound image. To our knowledge, however, either high or low echoic level of the normal parathyroid has been described without the confirmation of an experiment. Therefore, the echogenicity of the normal parathyroid was studied using intraoperative ultrasound. Materials and methods: Between October 2015 and January 2016, the parathyroid was examined in thyroidectomy procedures of 16 contiguous patients with thyroidal disease using an intraoperative array 8 – 18 MHz probe sheathed with a sterilized covering. There were 12 female and 4 male patients with an age range of 29 – 74 years old (mean, 47 ± 15). After one thyroid lobe or whole thyroid gland was removed, the parathyroid was found out by the surgeon. Then the parathyroid was scanned directly and through frontally-padded muscle of the neck, respectively. Results: The pathology results were thyroid papillary carcinoma (n = 11), thyroid medullary carcinoma (n = 2), thyroid adenoma (n = 1), retrosternal nodular goiter (n = 1), and thyroid nodular goiter (n = 1). Totally, twenty-five parathyroids were scanned in operation, including 8 right superior, 6 right inferior, 6 left superior, and 5 left inferior glands. All the parathyroids were visualized as hyperechoic structures, being homogeneous in texture (n = 22, 88%) and oval (n = 20, 80%), round (n = 3, 12%), or strip-like (n = 2, 8%) in shape. The length, width, and thickness averaged 6.8 ± 2.9 mm (range, 4 – 18 mm), 4.3 ± 1.6 mm (range, 3 – 10 mm), and 3.5 ± 1.3 mm (range, 1 – 7 mm). Conclusion: The normal parathyroid was confirmed to have a hyperechoic echogenicity, with most of them being homogenous and round-shaped, and measuring an average size of 6.8 × 4.3 × 3.5 mm through intraoperative ultrasound.

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

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

Retrosternal Goiter: 30-Day Morbidity and Mortality in the Transcervical and Transthoracic Approaches.

Retrosternal goiters pose a significant challenge in determining the indications and appropriate approach for surgical removal while limiting postoperative morbidity and mortality. The objective of this study is to use the National Surgical Quality Improvement Program (NSQIP) database to compare outcomes of transcervical and transthoracic approaches for retrosternal goiter removal and to review the literature regarding the varying indications for the 2 surgical approaches. Administrative database analysis. NSQIP database. The NSQIP database was queried for all cases of retrosternal thyroid: 2716 patients were included, which represents one of the largest data reviews of patients with retrosternal thyroid pathology who underwent surgery. Data were analyzed to examine morbidity and mortality of the cervical and transthoracic approaches. Patient demographics and preoperative comorbidities were similar between groups. Patients undergoing a transthoracic approach experienced increased rates of unplanned intubations and need for transfusion and length of stay postoperatively. A transthoracic approach is associated with increased rates of several critical postoperative morbidities, and the data indicate the potential of increased overall mortality. Given equivalent retrosternal extension, a transcervical approach should be attempted whenever anatomically possible, regardless of pathology.

Bilateral Chylothorax Secondary to Retrosternal Goitre: a Case Report and Review of the Literature

Chylothorax is characterized by an accumulation of lymphatic fluid in the pleural cavity due to damage to the thoracic duct. The aetiology can be traumatic or non-traumatic. Goitre is a rare cause of chylothorax with only eight cases previously described in the literature including only one case causing a bilateral chylothorax. This report describes a patient with bilateral chylothorax secondary to substernal goitre, which was successfully treated, and discusses this very rare case in light of the available literature.LEARNING POINTSPleural ultrasound and aspiration is important in bilateral pleural effusions unresponsive to diuretic treatment, or of dubious origin.The aetiology, diagnosis and treatment of a chylothorax are described.Goitre can cause chylothorax by damaging the thoracic duct.

Analysis of Retrosternal Goiter among Thyrodectomized Patients in Benghazi

Analysis of Retrosternal Goiter among Thyrodectomized Patients in Benghazi

A Large Superior Mediastinal Mass: “Terrible Thyroid Cancer”

Anterior mediastinal masses arise from a diverse group of conditions including thymoma, teratoma, retrosternal goiter, thoracic aortic lesions and lymphoma. We report a case of a 70-year-old male with anterior mediastinal mass who on further evaluation was found to have a large mediastinal lymph node secondary to a papillary thyroid cancer. Metastatic lymph node mass from thyroid malignancy should also be considered as one of the differential diagnosis in the evaluation of anterior mediastinal mass. J Endocrinol Metab. 2016;6(1):27-29 doi: http://dx.doi.org/10.14740/jem325w

A Limited Thoracocervical Approach for Accessing the Anterior Mediastinum in Retrosternal Goiters: Surgical Technique and Implications for the Management of Head and Neck Emergencies

In this article we describe the surgical management of retrosternal goiters via a limited thoracocervical approach, and we explore how the respective surgical know-how can be used in the management of the carotid blowout syndrome. Four cases involving patients who had undergone thyroidectomy via a limited thoracocervical approach are retrospectively reviewed. An acute blowout of the innominate artery managed with the same principal surgical technique is also reviewed. Three patients had a total thyroidectomy and one had a hemithyroidectomy. No malignancy was found. There was no mortality or unexpected morbidity from the limited thoracocervical approach. The median length of the inpatient stay was 3 days. The blowout survivor lived for 9 months, with no rebleeding and with an acceptable quality of life. We conclude that a limited thoracocervical approach can be safely performed by head and neck surgeons for accessing the anterior mediastinum in retrosternal goiters, and the respective surgical know-how can be used in the immediate management of an acute carotid blowout syndrome with satisfying long-term results and provision of quality end-of-life care.

Surgical Approaches to Retrosternal Goiter, When Sternotomy Is Mandatory? National Cancer Institute Experience (NCI), Cairo University, Egypt

Background: Retrosternal goiters (RG) are those lesions extending to occupy the thoracic cavity. They carry a surgical risk due to distorted anatomy, the minimal access, and the potential for great vessels or pleural injury. No other effective therapeutic alternative to surgery exists. Cervicotomy is still the surgical approach of choice, although a form of sternotomy may always be necessary for field extension and safe gland delivery. Materials and Methods: This is a single institution combined retrospective & prospective study including retrospective analysis of all cases presenting to the NCI, Cairo University with RG candidate for surgery between Jan. 2008 until the end of Dec. 2012, and a prospective study of all cases with the same presentation presenting to the NCI between Jan. 2013 until the end of Dec. 2015. Data was collected from archive of patients at the statistical department. Aims: To study the clinico-pathological characteristics, the presentation, work-up, surgical approaches and postoperative complications of RG. Results: 42 patients were included & were divided into benign (34 patients, 80.9%) and malignant groups (8 cases, 19.1%). All patients (100%) were adults ranging (19 to 73 years) with mean 53.1 years. There was a female predominance (36 female, 85.7%) versus (6 males, 14.3%). Median duration of symptomatology was 23 months ranging (6 - 53 months). 23 patients (54.7%) were symptomatic while 19 cases (45.3%) accidently discovered. Mean tumor size was 9.97 cm in the benign group and 11.1 cm in the malignant group. 31 patients (73.8%) were euthyroid, 9 (21.4%) were thyrotoxic and 2 (4.7%) were hypothyroid. All patients (100%) underwent total thyroidectomy. The commonest approach was cervicotomy (33 cases, 78.6%), while a type of sternotomy was done in 9 cases (21.4%). 2 cases (4.7%) received postoperative radiation therapy & 4 cases (9.5%) received postoperative radioactive iodine. No perioperative mortality occurred & the overall morbidity was 6 cases (14.2%) in the benign group and 2 cases (4.7%) in the malignant group (4.7%). The median follow up period was 17.5 months. The median overall survival (OS) was 39.4 months and the median disease free survival (DFS) was 9.8 months for the malignant group. Conclusion: Cervicotomy is a safe favorable approach to remove a RG. Intraoperative field extension up to a form of sternotomy may be necessary for gland delivery with increasing operating time, hospital stay and morbidity. Postoperative morbidity is mainly due to the respiratory, recurrent laryngeal nerve palsy and hypoparathyroidism which is mainly increased when sternotomy is performed.

Clinicopathological Analysis of Mediastinal Masses: A Mixed Bag of Non-Neoplastic and Neoplastic Etiologies.

The mediastinum is the central portion of the thoracic cavity, housing numerous organs and harbouring a mixed bag of non-neoplastic and neoplastic lesions. Accurate diagnosis is essential owing to the widely variable therapeutic and prognostic implications. Cases of mediastinal masses were retrospectively reviewed from January 2011 till January 2016. Clinico-radiological records of these cases were retrieved. Fine needle aspiration cytology (FNAC) was performed wherever feasible. Histopathological and immunohistochemical evaluation of the excised specimens was undertaken. Of the 60 cases included in our study, 22 were anterior, 20 were middle and 18 posterior mediastinal masses. The majority of the patients were symptomatic (96.8%). The most common pathology was thymoma (12 cases) followed by ten cases of lymphoma, eight cases each of tubercular lymphadenopathy and schwannoma, six cases of neurofibroma, four cases of extragonadal germ cell tumours, two cases each of thymic cyst, bronchogenic cyst, retrosternal goitre, ganglioneuroma and neuroblastoma, and one case each of lipoma and thymolipoma. FNAC was done in 54 cases of which 7 cases yielded inadequate material. Immunohistochemistry was required for classification of lymphoma cases and confirmation of a mixed component in germ cell tumours. Mediastinal masses create significant diagnostic dilemma for the clinicians, radiologists and histopathologists. While imaging studies help in narrowing the differential diagnosis, accurate categorisation is not always possible. FNAC is a useful and cost effective tool. However, sampling error and complexities in performing the technique are major hurdles in the usefulness of this diagnostic modality.