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PubMed2005

[Large mediastinal mass of heterotopic thyroid tissue: a case report and review of literature].

Incidental detection of a mediastinal mass in a asymptomatic patient poses a not easy diagnostic problem. For solid masses or cysts, histology or cytology is often necessary. Although substernal extension of a cervical goiter is common, totally intrathoracic primary thyroidal mass is unusual. We describe a rare case of heterotopic accessory mediastinal thyroid in a patient completely asymptomatic both for signs of thyroid dysfunction and mechanical compression. Radiological and hormonal 6 and 12 months follow-up is reported.

Adult↗
PubMed1998

Surgical aspects of 175 mediastinal goiters.

OBJECTIVE: Clinical picture and surgical management of 175 mediastinal goiters are discussed in this retrospective study. METHOD: Between 1979 and 1996, 175 patients with intrathoracic goiters were operated on at the Thoracic Surgical Clinic in Budapest. The majority of the goiters were cervicomediastinal (n = 138, 79%), past the level of aortic arch, and the others were complete aberrant lesions (n = 37, 21 %). Of the patients, 40% (n = 70) were symptom-free, in the others the clinical picture was dominated by compressive symptoms, among them, in five instances, the initial false, long-lasting diagnosis was bronchial asthma and, in four cases, vena cava superior syndrome caused by advanced inoperable malignancy. Twenty-two percent of patients (n = 39) were operated on previously for cervical struma. Eleven percent (n = 19) of the patients had hyperthyroid symptoms. In 124 cases the goiters were located in the anterior mediastinum. The majority (n = 96) of cervicomediastinal goiters (n = 138) could be removed through a cervical access, in the others an additional sternotomy (n = 31), or anterior thoracotomy (n = 11) were necessary. For resection of complete intrathoracic goiters (n = 37) standard thoracotomy (n = 30) or median sternotomy (n = 7) were used guided by retrotracheal or substernal position. RESULTS: Hospital mortality was 1.1%. Minor complications occurred in 46 cases (26%) and laryngeal nerve palsy in 14 patients (8%). Tracheomalatia developed in 18 patients (10%) which were mainly solved by tracheal intubation for 4-6 days. Ninety-four percent (n = 165) of the lesions proved to be diffuse colloid or adenomatous goiters by histology and 10 were (mostly follicular type) carcinomas. CONCLUSIONS: Unrecognized mediastinal goiters can produce asthma like symptoms, which may lead to late or misdiagnosis and deficient treatment. Once the diagnosis and exact extent of mediastinal goiter is established, multimodal surgical approaches are indicated for its safe removal - before occurrence of compressive symptoms.

Adenocarcinoma, Follicular↗
PubMed2006

Retrosternal thyroid goiter: 15 years experience.

BACKGROUND: Thyroidectomy for goiter is a common surgical procedure performed in most hospitals in Israel. Both general and ear, nose and throat surgeons are familiar with thyroidectomy for cervical goiters. In about 1-15% of thyroidectomies, the goiter is intrathoracic and requires somewhat different management. This topic has not been reviewed in the literature recently. OBJECTIVE: To evaluate the clinical presentation, preoperative workup, surgical complications and risk of malignancy in retrosternal goiters. METHODS: We retrospectively reviewed the records of 75 patients who underwent thyroidectomy for retrosternal goiter in the General Thoracic Surgical Department of our institution during a 15 year period, January 1990 to January 2005. RESULTS: All the patients (41 women and 34 men) were symptomatic at presentation, with choking and dyspnea being the most common complaint. Computerized tomography scan of the neck and chest were obtained before the operation in 71 patients (95%). Ten patients (13%) had a previous partial thyroidectomy. A cervical approach was used in 68 patients (91%). Seven patients (9%) required median sternotomy to complete the operation. One patient (1.3%) died from postoperative respiratory failure. Transient recurrent laryngeal nerve palsy occurred in 5 patients (7%) and permanent RLNP in 3 (4%). The incidence of transient and permanent hypoparathyroidism was 10% and 2.6% respectively. Sixty-six lesions (88%) were benign and 9 (12%) were malignant. CONCLUSIONS: Choking and dyspnea are the most common presenting symptoms of retrosternal goiter. CT scan is an important component of the preoperative evaluation and operative planning. Surgical removal of the thyroid is the treatment of choice and most patients have symptomatic improvement following the operation. Since a substernal thyroidectomy may be technically different from cervical thyroidectomy, a surgical team familiar with its unique pitfalls should perform the procedure.

Adult↗
PubMed1994

[Endemic goiter in a non-goitrogenic country].

Although goiter is not endemic in Israel, an iodine-rich country due to its bordering on the Mediterranean, we see many adults with massive goiters among immigrants from Afro-Asian and eastern European countries. 702 thyroidectomies were performed between January 1986 and March 1993 and 39 consecutive cases of goiter were studied. The patients ranged in age from 32-83 years (mean, 48); the female/male ratio was 36/3. There were 15 cases (13%) of thyroid carcinoma. In 1 case hyperthyroidism was diagnosed and treated preoperatively (3%) and in 2 others subclinical hypothyroidism was found (5%). The cervical approach was used, including cases with substernal extension. In only 1 was sternal splitting necessary. In our experience enlarged nodular goiter, with or without substernal extension, should be operated before symptoms of tracheal pressure develop and to avoid the risk of neglected malignancy hidden in an enlarged thyroid.

Adult↗
PubMed2001

Thyroidectomy for selected patients with thyrotoxicosis.

OBJECTIVE: To examine the indications for operation and the frequency, efficacy, and outcome of surgical therapy for thyrotoxicosis. METHODS: The medical records of all patients who underwent thyroidectomy between 1990 and 1998 were reviewed. Operative indications, laboratory evaluations, extent of thyroidectomy, pathologic findings, and morbidity and mortality were determined for patients with thyrotoxicosis. RESULTS: Of the 347 patients who underwent thyroidectomy, 54 (16%) had thyrotoxicosis, secondary to Graves' disease (32 patients), toxic multinodular goiter (18 patients), thyroiditis (2 patients), or amiodarone (2 patients). The indications for operation were compressive symptoms or substernal extension or both (35 patients), patient preference (12 patients), thyrotoxicosis (4 patients), or a dominant nodule (3 patients). Most patients received pharmacological preparation, followed by total (32 patients), near-total (13 patients), subtotal (8 patients), or unilateral (1 patient) thyroidectomy. The initial 8 patients with Graves' disease underwent subtotal thyroidectomy, and after a mean 28-month follow-up, 1 was euthyroid; 2, hyperthyroid; and 5, hypothyroid. Associated carcinoma was present in 4 (7%) of the 54 patients. Symptomatic hypocalcemia occurred in 10 patients (19%), with a mean free thyroxine level of 60.49 +/- 16.09 pmol/L vs 40.41 +/- 19.56 pmol/L (4.70 +/- 1.25 ng/dL vs 3.14 +/- 1.52 ng/dL) in 25 patients (46%) with asymptomatic hypocalcemia (P<.05). Vocal cord paresis and a hematoma requiring operative evacuation occurred in 1 patient each. There was 1 mortality in a patient with amiodarone-induced thyrotoxicosis. CONCLUSIONS: Massive thyroid enlargement with compressive symptoms, a dominant nodule, and patient preference are indications for surgical treatment of thyrotoxicosis. Near-total or total thyroidectomy is safe and more effective than subtotal thyroidectomy in preventing recurrence and should be considered in most patients referred for surgical treatment of thyrotoxicosis. Transient postoperative hypocalcemia is common and is related to the severity of thyrotoxicosis.

Adult↗
PubMed1995

[Does Iodine 131 treatment of goiter result in an acute increase of the volume and function of the thyroid gland?].

Many textbooks claim that radioiodine (131I) treatment should be avoided in treatment of a goitre with substernal extension, due to fear of acute swelling of the gland with resulting respiratory problems. We examined patients with multinodular goitre, either nontoxic (n = 20) or toxic (n = 10) after treatment with 131I. An ultrasonically determined thyroid volume and thyroid function variables were investigated before and two, seven, 14, 21, 28 and 35 days after treatment. In nontoxic goitres the thyroid volume did not increase significantly, the maximum increase in the median volume being 4% on day 7. Serum levels of free T3 and free T4 indices increased by 20% (day 7) and 13% (day 14) (p = 0.002), respectively. Likewise thyroid volume in toxic nodular goitre did not change significantly after 131I treatment. None of the patients presented symptoms of tracheal compression. We conclude that 131I treatment of nontoxic as well as toxic multinodular goitre does not seem to increase thyroid volume.

Adult↗
PubMed2001

Minimally invasive video-assisted approach for partial and total thyroidectomy: initial experience.

BACKGROUND: We report our initial experience with partial and total thyroidectomy using a video-assisted approach. The feasibility, safety, and potential benefits of this technique are examined. METHODS: Between January and May 2000, 28 patients were select to undergo a thyroid lobectomy (n = 17) or total thyroidectomy (n = 11) by a video-assisted cervical approach. Patient selection was based on clinical examination and preoperative ultrasonography. The surgical procedures were conducted under general anesthesia through a minimal substernal skin incision. Frozen sections were examined peroperatively in all cases. RESULTS: The initial diagnosis was solitary nodule in 19 patients and multinodular goiter in 8 patients. One patient was treated for hyperthyroidism. The mean cranio-caudal axis and transverse diameter of the resected specimen were 4.9 +/- 0.9 and 2.7 +/- 0.5 cm, respectively, and the mean total lobar weight was 11.9 +/- 5.5 g. Conversion to conventional surgery was required in three patients (10.7%), due to local bleeding in all cases. The mean operative times were 150 +/- 8.2 and 102.5 +/- 17 min for total and partial thyroidectomy, respectively. The laryngeal nerve was identified in 94.8% of cases. The mean length of skin incision was 25.4 +/- 2 mm. There was one case of postoperative hypocalcemia and one case of postoperative hoarseness. One patient had a transient vocal cord palsy. The postoperative hospital stay was 1 day for 66.7% of patients. The pain intensity evaluation, performed on postoperative day 1 using the visual analogue scale (VAS) method, was 1.9 +/- 1.4. CONCLUSION: Video-assisted thyroidectomy is feasible, safe, and effective in selected cases. Benefits for the patients in terms of postoperative pain, hospital stay, and cosmesis still need to be assessed in a prospective trial comparing standard open and video-assisted approaches.

Adult↗
PubMed1998

Surgical management of the substernal thyroid gland.

From 1992 to 1996, 19 patients had surgical resection of a substernal thyroid gland at the University of Rochester Medical Center, Rochester, New York. Based on a retrospective review of the 21 procedures performed, an algorithm for evaluation and surgical intervention is proposed. A limited medical workup is indicated and consists of a chest x-ray, thyroid function tests, computed tomography scan, and, possibly, fine-needle aspiration. Given a modestly high malignancy rate (16%) and a 37% reoperative rate, total thyroidectomy should be performed. When extensive mediastinal disease is encountered, a median sternotomy affords excellent access to the substernal thyroid gland.

Adult↗
PubMed1994

[New aspects in surgery of the thyroid gland with intraoperative monitoring of the recurrent laryngeal nerve].

A method for electrophysiological monitoring of the recurrent laryngeal nerve during thyroid surgery is described. An electromyographic record from the muscles of the vocal folds is obtained using two fine needle electrodes. The electrodes are placed endoscopically. The nerve is identified by electrical stimulation, and the electromyographic activity is registered using a Nerve Integrity Monitor NIM-2 (Xomed-Treace). Our experience with this method in 43 patients is described. The safety of the integrity of the recurrent laryngeal nerve is increased using intraoperative monitoring. This has led to a modification of the operative concept in thyroid surgery. Electrophysiological monitoring is mandatory in surgery of large goitres, retrotracheal and substernal extension, for re-operations and malignant diseases of the thyroid gland.

Electric Stimulation↗
PubMed2003

[Egg shell calcification of the substernal goitre].

Seventy one years old woman admitted to our clinic with the complaints of fever, cough and palpitation. Physical examination revealed a palpable thyroid with a 2 cm in length in its isthmus and large right lobe. Kyphotic patient was tachycardic. Other systems were within normal limits. Chest x-ray performed wide upper mediastinum with calcified nodule approximately 3.5 cm in dimension in the apex of the left lung. Computed tomography revealed thyroid gland lying through the upper mediastinum and a mass 3.5 x 3.2 cm in dimension in the left lobe inferior regio of the gland surrounded with calcification. Thyroid function tests showed hyperthyroidism. Clinically patient had a substernal multinodular goitre. Since the lesion demonstrating egg shell calcification at the apex of left lung in the chest roentgenogram belonged to substernal goitre, the case was accepted interesting and presented below.

Aged↗
PubMed2002

Thyroid volume measured by ultrasonography and CT.

PURPOSE: To evaluate measurements of thyroid volume by two different US methods and CT in a blinded design. MATERIAL AND METHODS: Four observers evaluated 27 patients. Observer 1 used US and calculated thyroid volume based on recordings of cross-sections through the gland. Observer 2 used US and calculated the volume of each lobe as a rotation ellipsoid. Observers A and B used CT images and calculated thyroid volume based on recordings of cross-sections through the gland. All measurements were made twice. RESULTS: The median thyroid volume was 81 ml (range 7-470 ml) evaluated by CT. All three methods had fair reproducibility. When correlating the two different methods using US, an r of 0.837 was found. When correlating data from patients without intrathoracic goitre evaluated by US (Observer 1) and CT, r = 0.945. The method based on a rotation ellipsoid systematically produced smaller thyroid volumes than those of the cross-sectional method. Evaluation by US systematically produced smaller thyroid volumes than CT. CONCLUSION: Calculation of thyroid volume based on US recordings of cross-sectional areas is a reproducible method in patients without substernal goitre extension. The US method calculating thyroid volume as a rotation ellipsoid is less reproducible, especially in large goitres. Measurement of thyroid volume using CT should be preferred in goitres with substernal extension.

Adult↗
PubMed2001

[Should we operate goiter in the elderly?].

The aim of this study was to compare the elderly patients group to the group of others undergoing surgical treatment due to goitre regarding type of goitre, extent of surgical procedures and postoperative follow-up (including early postoperative complications). 5872 patients with various type of goitre (between 1984 and 1998) were surgically treated, among them were 5244 (89.3%) females and 628 (10.7%) males (sex ratio as 8.1:1). The mean age was 46.1 (10 to 95 years). 278 (4.7%) patients were above 70 years of age (235-84.5% females and 43-15.5% males), their mean age was 73.7 years. The increase of malignant goitre was evident among the elderly patients (19.9% vs 5.5%). The dominant types were anaplastic cancers and malignant non-Hodgkin lymphomas. Much more frequently a giant goitre was diagnosed (20% vs 6.1%). It was localised substernally (39.6%) or intrathoracic (4.7%). The elderly prepared properly underwent surgical treatment quite well. Among early postoperative complications in the elderly dominant were surgical ones (6.8%), most frequently the injuries of the recurrent laryngeal nerve (4.67% vs 1.14%). Perioperative mortality regarded mostly the elderly with disseminated anaplastic cancer (3.6% vs. 0.2%). Surgical treatment of goitre in the elderly is a safe and justified method. High incidence of malignant tumours especially anaplastic cancers among the elderly should encourage to operation as early as possible.

Adolescent↗
PubMedDate not supplied

Mediastinal goitres: when the transthoracic approach?

The correct surgical approach to mediastinal goitre is not always well defined. We reviewed why and when our patients required a transthoracic approach. From 1979 to 1998, on 7.480 patients who underwent thyroid surgery in our hospital, 374 (5%) had a goitre whose greater bulk was inferior to the thoracic inlet; 43 patients of these last ones (11%) required a transthoracic approach. General anaesthesia was performed in all patients and orotracheal intubation was selective in 11 cases (double lumen tube of Carlens). In 34 cases, the first approach was a cervicotomy, followed by sternotomy in 23 cases or right posterolateral thoracotomy in 11 cases. Three patients underwent a sternotomy and 6 a thoracotomy only. We had neither perioperative mortality nor major complications. The mean hospital stay was 5 days. Mean goitre weight was 430 g and on average the greater diameter was 13 centimetres. The removal of a substernal goitre can be difficult and risky via the cervicotomy only. A transthoracic approach is often required in the case of greater secondary, primary and recurrent mediastinal goitres.

Adult↗
PubMed1998

99Tc(m)-MIBI scanning of the thyroid gland in patients with markedly decreased pertechnetate uptake.

Diffusely reduced 99Tc(m)-pertechnetate uptake is a relatively infrequent but annoying finding that impairs evaluation of the thyroid gland. We studied 32 female patients aged 19-85 years with markedly reduced pertechnetate uptake. The following causes of reduced pertechnetate uptake were recognized: treatment with iodinated pharmaceuticals (n = 15), suppression therapy with T4 (n = 11), subacute thyroiditis (n = 5) and massive tumour replacement (n = 1). 99Tc(m)-MIBI thyroid scintigraphy was performed within 24 h of the pertechnetate study. The results were correlated with neck ultrasound, serum TSH (n = 25) and surgical findings in patients who had been operated on. The technique identified the following conditions: normally sized thyroids (n = 4), diffuse goitres (n = 8), multinodular goitres (n = 17) and solitary thyroid nodules (n = 3). Moreover, substernal goitres were identified in nine patients. This condition was confirmed at surgery in seven patients. Ultrasonography was concordant in 29 of 32 patients in terms of thyroid size and structure, but failed to demonstrate substernal thyroid tissue. Our results suggest that 99Tc(m)-MIBI scintigraphy may contribute to the diagnosis of thyroid pathology and treatment planning in patients with diffusely decreased 99Tc(m)-pertechnetate uptake.

Adult↗
PubMed2006

Management of life-threatening airway obstruction caused by benign thyroid disease.

INTRODUCTION: Goitre presenting with acute, life-threatening airway compromise is an uncommon indication for thyroid surgery. The management of this critical condition is controversial. AIMS: To investigate the incidence of life-threatening airway compromise in patients with benign goitre, to investigate the predisposing factors, and to outline an optimal management policy for such critical cases. METHODS: Retrospective review of the medical records of patients presenting with life-threatening, acute airway compromise secondary to benign thyroid disease, treated by the senior author (CT) between July 1994 and July 2005. RESULTS: Of a total of 505 thyroid surgery procedures over the 11-year period, five patients with benign thyroid disease had presented with life-threatening, acute airway compromise. Three of the five patients had been thyrotoxic and two of these had received an iodine load prior to airway compromise. Immediate endotracheal intubation for airway control followed by admission to the intensive care unit had been the presentation in two patients. An incidental diagnosis of tracheal compression had been made from the computed tomography (CT) scan in two patients who had non-resolved obstructive airway disease. Emergency thyroidectomy had been performed in all five patients. Significant tracheomalacia had been noted in four patients. Following thyroidectomy, two patients had required tracheostomy and one had required tracheal stenting. CONCLUSION: Chronic obstructive airways disease, substernal extension and long-standing goitre are considered as risk factors for developing acute, life-threatening airway compromise in the presence of benign thyroid disease. A recent iodine load may lead to airway compromise in thyrotoxic patients. A CT scan is indicated in cases of unresponsive chronic obstructive airways disease to rule out substernal extension of non-palpable goitres. Life-threatening airway compromise secondary to benign goitres is best treated by endotracheal intubation if conservative measures fail, followed by emergency thyroidectomy. Following surgery, close observation is mandatory to exclude airway compromise due to tracheomalacia and laryngeal oedema.

Aged↗