Retrosternal Goiter Research Articles

Radiologically Predicting When a Sternotomy May Be Required in the Management of Retrosternal Goiters

Surgery remains the most effective treatment for retrosternal goiters. These commonly present as asymptomatic lesions in elderly patients, but may also cause airway and esophageal compression and, less commonly, may also be malignant. Although the majority of these goiters are amenable to transcervical thyroidectomy, in a minority of patients sternotomy is required. The ability to predict the need for sternotomy before operation would allow for safer surgery and operative counseling, as well as improved logistical efficiency if coordination with thoracic surgeons is required. In this report, we assess the radiologic factors that might be predictive of the need for sternotomy. We performed a retrospective review of 97 retrosternal goiters for which thyroidectomy was performed within the otolaryngology department at Addenbrooke's Hospital, Cambridge, between 2001 and 2011. There were a total of 80 cervical excisions and 17 cases in which sternotomy was required. A detailed computed tomographic analysis of these 17 cases was undertaken to assess the predictive factors for the requirement of sternotomy. The factors assessed included posterior mediastinal extension, presence of an ectopic nodule, extension below the carina, extension below the aortic arch, a "conical shape" of the goiter, and tracheal compression. These were compared to the same factors in the control group of 80 patients, and Fisher's exact test was used to determine statistical significance. The significant predictive factors for sternotomy, were posterior mediastinal extension, extension below the carina, and a "conical" goiter in which the thoracic inlet becomes a ring of constriction (all p < 0.05). Our results suggest that it is possible to predict on the basis of computed tomographic imaging the need for sternotomy in retrosternal goiters.

Acute Presentation of Massive Retrosternal Thyrotoxic Goitres*

Approximately 5% of goitres extend below the thoracic inlet and can potentially become life threatening due to compression of the airway and major vessels. Approximately 7% of these goitres which require surgical resection will need an additional sternotomy to deliver the intra-thoracic component. Massive retrosternal toxic goitres presenting acutely are rare and are described infrequently in literature. We hereby present two cases of massive retrosternal thyrotoxic goitres presenting with acute respiratory failure, requiring non-invasive ventilation, as well as significant head and neck venous compression. Surgery on the thyrotoxic patient with a goitre, even if not significantly enlarged, is associated with a high peri-operative mortality due to cardiac instability and hemorrhage. We discuss the challenges of surgical intervention in these patients with particular emphasis on the timing of surgery to relieve compressive symptoms and the time needed to achieve a euthyroid state. We also emphasize the need for meticulous hemostasis, use of a cell-saver, transfusion protocols, adjuncts to hemostasis, as well as careful monitoring and continuous adjustments to the coagulation profile.

The Surgical Management of Retrosternal (Intrathoracic) Goiter

ABSTRACT Retrosternal (intrathoracic) goiter has a prevalence of 4 to 20% of patients undergoing thyroidectomy for multinodular goiter. Although it is a condition affecting the older patient with a peak incidence in the sixth decade, the majority should be treated surgically. With few exceptions the operation can be safely accomplished through a cervical approach, only a small minority (approximately 2%) needing a combined cervical/mediastinal procedure. The surgical steps for the routine case are described and also various technical maneuvers required to facilitate delivery and excision of the difficult large goiter. How to cite this article Wheeler MH. The Surgical Management of Retrosternal (Intrathoracic) Goiter. World J Endoc Surg 2013;5(1):28-30.

Significance of Prophylactic Paratracheal Lymphnode Dissection in A Case of Retrosternal Goitre: A Case Report

An elective or a prophylactic lymph node dissection is the removal of the lymph nodes that are normal on physical examination and on radiographic imaging. This type of dissection is not based on the visible disease in the targeted nodal basins, but on the potential of a radiographically occult tumour which can exist. The pathologic results of an elective lymph node dissection may help in predicting the risk of a future recurrence and, in some solid tumours, guide the delivery of the adjuvant therapy and as in this case, may contribute to a pathological diagnosis. The decision to proceed with an elective node dissection is based on the assessment of the risks and benefits of the procedure. The morbidity of the regional lymph node dissection must be balanced against the potential benefit of the procedure. A thyroid papillary microcarcinoma is defined according to the WHO criteria and Shaha as a thyroid tumour which is smaller than 1-1.5cm. Different terms are currently used to define this thyroid cancer such as small, tiny, minute, minimal or occult papillary carcinomas of the thyroid, impalpable thyroid carcinoma and incidental thyroid papillary cancer. A common clinical scenario is the incidental diagnosis of papillary thyroid microcarcinoma (PTMC) on the histology of the resected thyroid, following the surgery which was done for a presumably benign thyroid disease. PTMC was diagnosed in 7.1% of the patients with a presumably benign thyroid disease. It may be possible that this is an underestimation of the true incidence, because we did not use the serial sectioning technique and maybe because the PTMC which was present was so small that it was grossly not identified and sectioned. Herein, a case which was clinically suspicious and was radiologically and cytologically diagnosed as a case of retrosternal multinodular goitre underwent a near total thyroidectomy and a paratracheal lymphnode dissection. The node was found to have micrometastasis of the follicular variant of a papillary carcinoma and the thyroid, on a retrospective step sectioning, revealed an incidental PTMC. This case has been presented, to highlight the possibility of an incidental PTMC in the thyroid cases which were resected for benign disease and the importance of elective lymphnode dissection in contributing to the diagnosis of PTMC.

536. Retrosternal Goiter - is There a Need for Thoracic Approach?

Background: the incidence of retrosternal goiter (RSG) varies from 2% to 26% of all thyroidectomies, depending on the defining criteria. There is no clear guidelines to identify patients that require an intrathoracic approach. So, we tried to correlate, between the size and/or anatomical site of the RSG based on preoperative CT findings, and the surgical approaches used, aiming at defining those patients with RSG who are in need for thoracic approach.

Retrosternal goiter located in the mediastinum: surgical approach and operative difficulties

Most retrosternal goiters are situated in the anterior mediastinal compartment, but according to the literature, 10-15% are located in the posterior mediastinum. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a huge posterior mediastinal goiter extending from the neck retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side and ending at the level of the lower part of the left cardiac atrium, nearly reaching the diaphragm. Surgical removal is the treatment of choice in such cases. We performed an operation using a transcervical and right thoracotomy approach. Histopathological examination confirmed the diagnosis of the large goiter. The patient recovered well and was discharged in 1 week.

Combined cardiac surgery and substernal thyroidectomy

Excessive growth of the thyroid gland is frequently associated with multinodular goiter. Shifting of mediastinal structures and large airway obstruction via extrinsic compression by a mass effect can lead to additional surgical problems. In November 2008, a 65-year-old male patient with unstable angina pectoris was admitted to our clinic for coronary artery bypass grafting. A retrosternal mass lying over the ascending aorta precluded cannulation. After the resection of retrosternal goiter, cardiopulmonary bypass was performed with single right atrial and ascending aortic cannulation. Combined cardiac surgery and thyroidectomy can be safely performed if the preoperative thyroid hormone levels are maintained in the euthyroid state.

Pendred Syndrome with Retrosternal Goitre- A Rare Case Report

Pendred syndrome is a recessively inherited disorder characterized by goiter associated with sensory-neural deafness. The thyroid glands of affected individuals cannot organify iodide efficiently due to a defective gene in chromosome 7. Here we report a case of Pendred syndrome with retrosternal goitre.

Retrosternal goiter: The need for thoracic approach based on CT findings: Surgeon’s view

Background and purposeThe incidence of retrosternal goiter (RSG) varies from 2% to 26% of all thyroidectomies, depending on the defining criteria. There are no clear guidelines to identify patients that require an intrathoracic approach. So, we tried to correlate, between the size and/or anatomical site of the RSG based on preoperative CT findings and the surgical approaches used, aiming at defining those patients with RSG who are in need for thoracic approach. Patients and methodsOut of 1481 patients underwent thyroidectomy at the National Cancer Institute (NCI), Cairo University, between January 2000 and December 2009, only 73 (4.93%) of them had retrosternal extension. Demographic, clinical, operative, anatomical, and pathological data of patients with RSG were recorded and analyzed. ResultsThe intraoperative extension of the goiter correlated with the extension seen in the CT in all except two patients. Laterality and longitudinal extension found in preoperative CT, correlated well with the surgical findings. The approach used was cervical in 66 cases (90.4%); combined approach in six patients (8.2%). Pure thoracic (full sternotomy) was used alone in one case (1.4%). Extension of the RSG down to or below the arch was associated with an increased risk of using a thoracic approach p<0.0001. ConclusionPreoperative CT, can be used effectively to guide the indications for using a thoracic approach. Reaching the aortic arch or beyond and loss of fat planes in CT, recurrent and malignant disease, are significant risk factors for using a thoracic approach.

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

Incidental diagnosis of primary intrathoracic goiter on radionuclide 99m-tc pertechnetate radioisotope thyroid scan

Retrosternal goiters are classified into two groups. One is the truly primary intrathoracic or aberrant goiter. Presence of accessory thyroid tissue in the mediastinum of these patients group is congenital, with the blood supply derived entirely from intrathoracic vessels and it has no direct connection to the cervical thyroid gland. This primary intrathoracic goiter group represents less than 1% of surgically removed goiters. The much more common second group represents the acquired retrosternal goiter. It arises in the cervical thyroid gland and while growing it descends along a fascial plane, through the thoracic inlet into the mediastinum. Intrathoracic goiters usually present with clinical symptoms due to pressure on adjacent structures as the goiter enlarges within the rigid thoracic inlet. Asymptomatic large retrosternal, especially primary intrathoracic goiters are very uncommon. Here, we report a case of large retrosternal primary intrathoracic goiter found serendipitously on Technetium-99m (99mTc) pertechnetate radioisotope thyroid scan, which was missed on ultrasonogralhy (USG) neck in an asymptomatic patient presented with neck heaviness. Thus, here we emphasize the role of radioisotope thyroid scan over USG neck to diagnose retrosternal goiter.

Surgical management of retrosternal goiter: Local experience at a university hospital

BACKGROUND AND OBJECTIVE:Retrosternal goiter (RSG) is a term that has been used to describe a goiter that extends beyond the thoracic inlet. Surgery plays an important role in the treatment of these patients, but whether all or selected patients with RSG should undergo this operation remains controversial. Our aim is to look into the demographics, presentation, and treatment of patients with RSG and essentially to determine the role of surgery in its treatment.SETTING AND DESIGN:Retrospective study, teaching hospital-based.METHODS:Retrospective analysis of 537 thyroidectomies performed at King Khalid University Hospital between 2003 and 2010. The twenty-six patients with RSG were analyzed further, with regard to demographics, presentation, indications, and outcome of surgical treatment. Statistical analysis was performed, where age was expressed as mean and range, and other variables were presented as numbers and percentage.RESULTS:There were 26 patients (4.8%) with RSG out of 537 thyroidectomies, who underwent an operation for removal of RSGs, in a seven-year period. The most common presentation was dyspnea (34.6%) and the surgical procedure predominantly used was total thyroidectomy. The RSGs were removed by collar incision in 96% of the cases. The final histological diagnosis revealed malignancy in 26.9% of the thyroid specimens. There was no mortality and minor complications occurred in nine patients.CONCLUSIONS:The presence of an RSG is an indication for surgery owing to the lack of effective medical treatment, the higher incidence of symptoms related to compression, low surgical morbidity, and the risk of malignancy.

Combining Thyroidectomy with Cardiac Surgery: Implications for the Endocrine Surgeon

ABSTRACT The management of incidentally detected retrosternal goiter in patients with cardiac disease awaiting open heart surgery is controversial. Here, we present the case of a 79-year-old man; who had coronary artery bypass grafting, aortic valve replacement and thyroidectomy for retrosternal goiter under a single anesthetic. A literature search was conducted to study patient demographics, thyroid symptomatology, pathology, complications and the risks and benefits of the combined procedures. Literature search revealed only a few similar cases of a combined surgical approach and these are from the perspective of the cardiac surgeon. The study is presented to highlight the implications of such combined procedures for the endocrine surgeon. A medline search was conducted for combined procedures on heart and thyroid. Five case reports and two reviews, including one case of off-pump coronary artery bypass grafting (CABG) was obtained. The mean age of the patients was 69 years (range, 55-79). Retrosternal goiter was the commonest indication (67%), half of them presenting with tracheal compression. Thyrotoxicosis was observed in 22%. Beinign multinodular goiter was the commonest pathology (89%). There was one case of Grave's disease. There were no reported malignancies. There were no reported complications from the endocrine surgery. The various cardiac procedures in the combined operations were coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, a combination of these and a case of closure of atrial septal defect. The review has looked into the anatomical and physiological implications of combined operations, operative risks and has upheld the safety of such combined procedures. How to cite this article Daniel SV, Lansdown MR. Combining Thyroidectomy with Cardiac Surgery: Implications for the Endocrine Surgeon. World J Endoc Surg 2012;4(2):43-46.

Anesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing: the challenges imposed -A case report-

Anesthetic management of patients with mediastinal masses remains challenging as acute cardiorespiratory decompensation may follow induction of anesthesia. We describe a 57 year old lady with massive retrosternal goiter and severe intrathoracic tracheal compression who had a total thyroidectomy. Comprehensive contingency plans were an essential prerequisite for successful management of difficult airway, including multidisciplinary involvement of otorhinolaryngologic and cardiothoracic surgeons preparing for rigid bronchoscopy and cardiopulmonary bypass. Awake oral fiberoptic intubation was performed under dexmedetomidine sedation. Severe tracheal narrowing necessitated usage of a 5.0 mm uncuffed flexometallic endotracheal tube. Anesthesia was maintained with sevoflurane and dexmedetomidine infusion with target controlled infusion of remifentanil as analgesia. No muscle relaxant was given. Surgical manipulation led to intermittent total tracheal compression and inadequate ventilation. The tumor was successfully removed via the cervical approach. A close working relationship between anesthesiologists and surgeons was the key to the safe use of anesthesia and uneventful recovery of this patient.

Hogben on speed, paradoxes and strain*

Reflections’ section in this issue. 3 The patient studied had previously undergone surgery for thyrotoxicosis and was now suffering from symptoms of tiredness and weakness that might have either a physical or psychological cause. The study design involved creating a ‘chaotic’ sequential administration of placebo, prostigmine and amphetamine over several 3-day cycles of treatment with careful patient self-reports of experience across 10 outcomes, including mood, appetite and physical activity. Hogben had thyroid surgery in 1943 1 and from the small clues he gives in the paper [e.g. ‘his previous retrosternal goitre had been labelled as functional until he himself persuaded a surgeon to explore the affected area’; ‘the subject (H)’], it is apparent that he was the patient in the study. James Tabery considers that this study stems from Hogben’s interests in statistical inference and causal mechanisms at the individual level—the ‘tyranny of averages’. 4 Paul Glasziou notes that the earliest description of the N-of-1 design pre-dates Hogben and Sim’s by over 150 years, 5 but their approach was methodologically sophisticated and aimed to remove multiple sources of bias. The clinical relevance of the N-of-1 design, mirroring careful clinical practice, is so obvious that it is surprising that it has not become more widely used as a means of finding suitable treatments for patients with chronic conditions. The findings of the study are not commented upon but Hogben certainly felt much better on amphetamines. I wonder if he continued to take them as so many people did (British Prime Minister Anthony Eden allegedly relied on them during the Suez Canal crisis of 1956); they could be bought over the counter in a chemist shop without a prescription at that time. Alun Evans provides a diversion with a historical account of the French paradox of low levels of coronary heart disease despite high levels of fat intake first described in 1981. He traces the paradox to a comparison of the prevalence of angina between Ireland and France published in 1819. 6 He notes that the clin

Post-Thyroidectomy Tracheomalacia

Background Tracheomalacia is a feared complication of goitre surgery, but considered rare in the Western World. This study aimed to estimate the risk of tracheomalacia in a contemporary series of patients with goitres causing significant tracheal compression. Methods A retrospective review was conducted of thyroidectomies performed in a UK tertiary referral centre over a 30 month period. Anaesthetic, operative, radiological, and pathological data were obtained from medical notes and hospital software systems. Results Of 334 patients who underwent thyroid surgery, preoperative CT scan was performed in 101 (30%). Tracheal compression was reported in 62 patients (19%) with minimum tracheal diameter ranging from 2 to 15 mm (mean 7.6 mm) due to multinodular goitre (n=50), malignancy (n=10), or thyroiditis (n=2). Critical compression 5 mm. Conclusions We found no evidence of tracheomalacia in high-risk patients with significant tracheal compression. This supports prior work on retrosternal goitres suggesting that the risk of tracheomalacia is minimal in modern thyroid surgery. For risk management, however, we would still advocate that such patients be managed in units with multispeciality support.

Multinodular thyroid goitre causing obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome has been linked to obesity, nasal obstruction and adenotonsillar hypertrophy, but rarely to large thyroid goitres. To study the possible association between multinodular retrolaryngo-pharyngeal or retrosternal goitres and obstructive sleep apnoea syndrome. Retrospective case series at a tertiary referral centre (2000-2010). Study parameters included body mass index, Epworth sleep score and polysomnographic index. Five patients were diagnosed with obstructive sleep apnoea syndrome and managed with nasal continuous positive airway pressure ventilation. Computed tomography showed a retrolaryngo-pharyngeal or retrosternal goitre with significant tracheal compression, displacement and laryngeal oedema. After total thyroidectomy, obstructive sleep apnoea resolved in all patients. Large, multinodular goitres with retrolaryngo-pharyngeal extension can cause obstructive sleep apnoea syndrome due to laryngeal compression and oedema. In such cases, total thyroidectomy enables resolution of symptoms. Patients with obstructive sleep apnoea syndrome should be screened for thyroid goitre.

Threatening Airway Obstruction by Mediastinal Masses: The Experience of a Medical Intensive Care Unit

Objective: Life-threatening airway obstruction is a dreaded complication of mediastinal masses. The acute management is difficult and catastrophic outcomes have been reported. We describe our experience in a Medical Intensive Care Unit (ICU) and discuss the management options. Design: Retrospective observational study. Setting: 1,600-bed tertiary-care hospital. Patients and Participants: 13 patients were treated between January 1996 and February 2010. Interventions: All patients were mechanically ventilated. Three received emergent chemotherapy, 10 underwent airway stenting and 2 underwent surgery. Measurements and Results: The median age was 51 years (range 13 to 64). In 5 patients (36%), the diagnosis was only made after ICU admission. Two had benign pathologies (retrosternal goitre and bronchogenic cyst) and 3 had lymphoma. The remaining 8 had metastatic mediastinal lymphadenopathy. All were successfully weaned off the ventilator (range 0 to 5 days). All patients with benign pathologies and lymphoma were still alive with a mean follow-up of 2.8 years (range 1 to 7 years). All patients with metastatic disease died, with a mean survival of 3.8 months (range 1 to 9 months). Conclusion: In the management of life-threatening airway obstruction by mediastinal masses, we reported the heterogeneous nature of this group of conditions. Therefore in the intensive care setting, a definitive diagnosis needs to be established urgently, as treatment and prognosis are highly dependent on the underlying etiology. We propose categorising patients into subgroups and combining various therapeutic modalities.

Laparoscopic relief of meralgia paraesthetica

The positioning of patients for optimal access in thyroid surgery is paramount. We describe a technique whereby the angle of the neck can be greatly increased during the operation and then released to ensure a tension free closure using a common anaesthetic item. By positioning an Infusable® white nylon intravenous pressure bag (Vital Signs Inc, Totowa, NJ, US), or similar, underneath the patient's shoulder blades, the neck can be maximally extended by inflating the bag. It is easily and quickly deflated by the anaesthetist for closure. Benefits include improving access, elevating slightly retrosternal goitres from the thorax and removing the struggle with saline bags or other supports.