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PubMed2003

[Surgery of substernal thyroid goiter: 32 cases reported].

OBJECTIVE: To probe into the surgical approaches and operative techniques for substernal thyroid goiter. METHOD: In the way with operating on thyroid retrosternal thyroid tumour were removed via cervical collar incision and substernal thyroid cancer was partly removed via "perpendicular" shape cervical incision and tracheotomy. RESULT: The operations via cervical collar incision on 31 cases with substernal thyroid goiter have been carried out successfully. One thyroid cancer was partly moved via "perpendicular" shape cervical incision and tracheotomy, radiation therapy and isotope was adopted after operation, the patient survived above 5 years. Syndrome occurred in 9 cases (28.1%); recurrent laryngeal nerve were damaged in 5(15.6%), hemorrhage in 3(9.4%). CONCLUSION: Resection via cervical collar incision for all retrosternal thyroid nodules was advised and surgery for malignancy needs to be investigated.

Adenoma↗
PubMed1983

Effect of neck position during radionuclide superior cavography. Its value in the diagnosis of superior vena cava obstruction due to retrosternal goiter.

In five patients with substernal goiter, three of whom presented with superior vena cava (SVC) syndrome, and in five normal subjects, radionuclide superior cavography (RNSC) was performed with extension and flexion of the neck during tracer administration (simultaneous bilateral injection of Tc-99m pertechnetate). When the tracer was injected during neck extension, venous flow pattern was abnormal in four of five patients, and transit time (TT) prolonged in three of five patients. In this posture, mean TT +/- 1 standard deviation (SD) was 6.3 +/- 2.6 s (range 3.5 to 9 s) for the five patients and 3.5 +/- 0.7 s (range 2.5 to 4.5 s) for a group of five control subjects. When the tracer was injected during neck flexion, all five patients showed abnormal flow patterns and prolonged TT (mean +/- 1 SD 10.1 +/- 4.1 s; range 4.4 to 16 s), in contrast to the control group where a slight decrease in TT was found (mean +/- 1 SD 3 +/- 0.6 s; range 2 to 3.5 s). In the presence of a substernal goiter, or any mobile mass at the thoracic inlet, impairment of venous flow through the SVC system appears to be a common occurrence, readily detectable by RNSC. RNSC should be performed with neck flexion during tracer injection, since in this posture its ability to detect compromised venous flow through the SVC system is enhanced, even in patients without a clinically apparent SVC syndrome.

Adult↗
PubMedDate not supplied

[Substernal goitre. Personal experience].

INTRODUCTION: Aim of the study is to discuss the diagnostic and therapeutic problems of substernal goiter (SG). MATERIALS AND METHODS: The Authors retrospectively analyzed 12 patients (3.1%) with substernal goiters among 379 patients undergoing surgical treatment for thyroid diseases from January 2000 to 2005, and evaluated the clinical data, preoperative diagnostic findings, surgical treatments, histopathological results, and postoperative complications. RESULTS: The most common symptoms were a cervical mass (100%) and dyspnea (16%), but 50% of the patients were asymptomatic. Chest radiography provided the first evidence of a substernal goiter in 100% of the patients. The AA performed total thyroidectomy and operated through a cervical incision in all the patients. There was operative mortality (1 case: = 8%), 2 (16%) patients suffered temporary hypoparathyroidism; no patients suffered transient vocal cord paralysis. Malignancy was diagnosed by histopathological examination in 2 patients (16%). CONCLUSIONS: The presence of a substernal goiter is considerd as a sole indication for surgery. Surgical treatment of SG requires a diagnosis that exactly defines the extent of the lesion. A correct choice of surgical access and scrupulous operating technique are likewise of paramount importance to reduce the risk of severe compressive complications. Most retrosternal goiters can be resected through an entirely cervical approach with a low complication rate. On rare occasions a median sternotomy or a sternal split will be required to permit a safe and complete thyroidectomy.

Adult↗
PubMedDate not supplied

Parathyroid preservation during thyroid surgery.

PURPOSE: Even though thyroid surgery is generally quite safe, permanent hypoparathyroidism is a very distressing complication. The incidence of hypoparathyroidism is directly proportional to the extent of thyroidectomy, and inversely proportional to the experience of the surgeon. It is also related to the extent of invasion of thyroid cancer and of the degree of dissection in the tracheo-esophageal groove. The incidence reported in the literature varies between 1% to 29%. Total thyroidectomy results in a higher incidence of hypoparathyroidism. MATERIALS AND METHODS: This report describes experiences with 600 thyroidectomies over a period of 11 years. The major indications for surgery included suspicion or proof of malignancy, compression symptoms, and substernal goiters. Twenty-six patients underwent surgery for Graves' disease. There were 221 men and 379 women, ranging in age from 16 to 89 years; 88% of the patients had benign disease, whereas 12% of the patients had malignant pathology. The surgical procedures included 62 total thyroidecotmies, 188 subtotal thyroidectomies, and lobectomy and isthmectomy in 350 patients. RESULTS: Meticulous tracheo-esophageal groove dissection, identification of parathyroids and their preservation, including the blood supply, was routine in each case. Even in patients undergoing unilateral lobectomy, every effort was made to preserve the parathyroids. If any of the parathyroids or its blood supply was injured, it was autotransplanted in the sternomastoid muscle. Only two patients developed temporary hypoparathyroidism. CONCLUSION: Parathyroid autotransplantation is performed whenever one or more of the parathyroids are damaged. Parathyroid preservation during thyroid surgery is crucial in the overall management of thyroid diseases.

Adolescent↗
PubMedDate not supplied

Hyperthyroxinemia and hypotriiodothyroninemia with clinical euthyroidism.

A clinically euthyroid woman had substernal goiter and thrombocytopenia. There was a striking elevation in serum thyroxine (T4) level when the level of triiodothyronine (T3) ws low, reverse T3 (rT3) was normal I131 uptake was suppressed, and thyroid stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) was blunted. The elevation of T4 was transient and required no treatment. Postmortem examination revealed a thyroid gland that showed only multinodular goiter. Multiple factors contributed to the dissociation between T4 and T3 levels. There was a lack of clinical symptoms in the face of high T4 and normal T3. The report stresses the need for thorough evaluation of thyroid function in such cases before instituting treatment.

Aged↗
PubMed1982

Tc-99m pertechnetate uptake in a thymoma: case report.

A case is reported to Tc-99m pertechnetate accumulation within an anterior mediastinal thymoma during a search for substernal goiter. This reemphasizes the non-specificity of Tc-99m pertechnetate uptake and the need for caution in using this agent to detect ectopic thyroid tissue.

Diagnosis, Differential↗
PubMedDate not supplied

[Cervico-mediastinal carcinoma of the parathyroid: report of a case].

Parathyroid carcinoma is a rare malignancy. We report the case of a 66 years old man referred to our department for a large substernal goiter suspected as a thyroid cancer associated with severe hyperparathyroidism. After normalization of serum levels of calcemia, total thyroidectomy and subtotal parathyroidectomy was performed. Histopathology revealed a parathyroid cancer of 450 g.

Adenocarcinoma, Clear Cell↗
PubMedDate not supplied

Surgical management of substernal goitres. When is sternotomy inevitable?

PURPOSE: Aim of this retrospective study is to report personal experience in the surgical management of substernal goitres emphasizing the guidelines for preoperative planning of sternotomy in selected cases. PATIENTS AND METHODS: Medical records of all patients (n=355) submitted to thyroidectomy for struma in our Operative Unit, between 1993-2003, were analysed. A substernal goitre was defined as a goitre having a significant retrosternal extension (>50%) requiring mediastinal dissection. RESULTS: A total of 18 out of 355 patients undergoing thyroidectomy for struma in our Operative Unit had substernal goitres. The most common symptoms, at presentation, were the presence of neck mass and respiratory disorders. Standard cervical incision was adequate to achieve total thyroidectomy in 17 cases while, in one patient with computed tomography images showing the presence of a huge goitre extending below the aortic arch, a sternotomic approach was inevitable to ensure safe removal. No major morbidity or perioperative deaths occurred. One patient with scleroderma experienced bilateral paralysis of laryngeal nerves for two months, with full recovery thereafter. CONCLUSIONS: While removal of the majority of substernal goitres can be achieved by means of cervical incision, this approach is not always safe. In a selected number of cases with an iceberg shaped substernal goiter and with >70% of the volume lying below the thoracic outlet, a sternotomic approach is inevitable. Preoperative diagnostic work-up should, thus, include chest X-ray and computed tomography. Overall results in the present patient population, have been excellent since morbidity has been minimal and mortality absent, and all patients are symptom free.

Adult↗
PubMed1996

[Tracheal stenosis as the presenting form of follicular thyroid carcinoma].

Follicular carcinoma of the thyroid is an uncommon neoplasm, whose diagnosis is usually established upon evaluating a thyroid nodule. However, on occasions it can be presented with symptoms derived from the adjacent structures' compression, as the trachea, since only it is presented in reduced number of patients with substernal goiter. We present a rare case of a woman 73 years-old, with follicular carcinoma of the thyroid, that consulted for 5 years-old evolution dyspnea and wheezing, without finding alterations in the initial roentgenogram of the chest. We comment the difficulty in the diagnosis of the upper airway obstruction when the roentgenogram of the chest is normal, and we comment the clinical and pulmonary function data that can lead us to suspect this disease.

Adenocarcinoma, Follicular↗
PubMed1998

Intrathoracic aberrant thyroid: identification critical for appropriate operative approach.

True aberrant thyroid in the chest is a rarely described entity. More commonly, "aberrant" thyroid is a substernal goiter that is an extension of the cervical gland inferiorly and can be removed safely with the classic "collar" incision. Aberrant intrathoracic thyroid typically derives its blood supply from intrathoracic sources and requires an alternate surgical approach for adequate exposure. The ability to identify these rare intrathoracic thyroids is critical for safe surgical excision.

Aged↗
PubMed1996

Recurrent substernal nodular goiter: incidence and management.

BACKGROUND: Surgery for recurrent multinodular goiter is associated with an increased risk of complications. When recurrence occurs in a substernal location, difficulties associated with surgical removal may be even more significant. METHODS: Information relating to indications for surgery, procedure performed, pathologic findings, and surgical complications was obtained from a prospective thyroid surgery database maintained in our unit for the past 39 years. RESULTS: During the study period 234 patients underwent operation for retrosternal recurrence of a nodular goiter. In the majority of cases (51%) the indication for surgery was the presence of compressive symptoms. In only four cases was a sternal split required to remove substernal recurrence. Complications occurred in 35 patients, including four permanent recurrent laryngeal nerve palsies. No patient had permanent hypoparathyroidism. CONCLUSIONS: Surgery for recurrent substernal goiter, although technically demanding, can be performed with a minimum of morbidity if appropriate attention is paid to anatomy and embryology. A sternal split is only rarely required.

Adult↗
PubMedDate not supplied

[Intrathoracic goiter: experience with 61 surgically treated cases].

Sixty-one patients with substernal goiter--42 women and 9 men (female:male ratio 2.2:1), mean age 57.5 years--underwent surgical resection in the General and Thoracic Surgery Division of the Surgery Department of the University of Catania from January 1980 to March 1999. Six patients (9.8%) had previously undergone cervicotomy. Forty-nine patients (80.3%) had symptoms (2 with acute respiratory failure); 22.9% had metabolic symptoms. Fifty-one patients (83.6%) had cervicomediastinal goiter, 8 (13.1%) migrated mediastinal goiter and 2 (3.3%) ectopic goiter. Forty-one cases (69.5%) were prevascular and 18 (30.5%) retrovascular; of the latter 5 were pre-visceral and 13 retrovisceral. Fifty-one thyroidectomies (6 subtotal) were performed, as well as 5 mediastinal excisions to complete removal and 4 resections confined to the mediastinal component. The 51 patients with cervicomediastinal goiter underwent cervicotomy in 42 cases (82.4%), cervicosternotomy in 7 cases (13.7%) and cervicosternothoracotomy in 2 cases (3.9%). The 8 migrated mediastinal goiters were removed via sternotomy in 6 cases, cervico thoracotomy in 1 and thoracotomy in 1. This latter approach was also used for the 2 ectopic goiters. The goiter presented signs of neoplastic degeneration in 2 cases (3.2%). Postoperative complications were: recurrent nerve palsy in 5 cases (1 bilateral definitive, 1 monolateral definitive, 3 monolateral transient), respiratory failure in 2, mediastinal hematoma in 1 and hypocalcemia in 8 (transient in 6). There was one postoperative death due to cardiorespiratory failure after cervicosternotomy. Surgical excision of substernal goiters is the best choice of treatment in view of the very low postoperative mortality and morbidity.

Female↗
PubMedDate not supplied

The impossible intubation--what next?

A patient is presented in whom endotracheal intubation was impossible secondary to an obstructing substernal goiter and laryngeal spasm. Cardiopulmonary bypass was utilized to provide safe induction of anesthesia and intubation so that the substernal goiter could be removed. Other alternative methods in anesthetic management are discussed.

Aged↗
PubMed1992

Mediastinal goiters. The need for an aggressive approach.

We reviewed the cases of 52 patients with substernal goiters to examine clinical presentation, workup, technique of removal, malignancy, and outcome. Half of the patients were asymptomatic; half had at least one compressive symptom. Chest film was the most used; computed tomography or magnetic resonance imaging was by far the most useful study. Thyroid scans often failed to show the intrathoracic goiter. Fine-needle aspiration was not helpful because of the gland's inaccessibility. Seventeen percent (nine) of the thyroids showed malignancy, 21% (11) including incidental papillary carcinomas. These were not identified by duration of goiter, symptoms, or fine-needle aspiration. Except for lymphomas, prognosis was good after resection. Removal was almost always accomplished via cervical incision, with low morbidity and no deaths. The threat of compression, the substantial chance of malignancy, and the safety of resection mean that the presence of substernal goiter is an indication for surgery.

Academic Medical Centers↗
PubMedDate not supplied

[Endothoracic goiter operated on by cervicosternotomy. Apropos of 18 cases].

From 1968 to 1992, 18 sternotomies were performed on a total amount of 225 operated substernal goiters (8% of cases). These operations concerned 14 females and 4 males aged of about 67.8 years. 7 patients had already been operated of a goiter within 1 to 50 years. The substernal goiter was discovered on a systematic x ray chest 5 times, and a x-ray scanner once, also clinical symptoms were still present with compressive troubles in 16 times (particularly acute dyspnea 3 times). The sternotomy was always total. It was only required if the operative problems were important at the time of the cervicotomy. Indications for sternotomy were:--impossibility to extraction due to the volume of the goiter 10 times, (including 5 recurrent goiters), independent retrosternal goiter without cervical connexion, 2 times (including 2 recurrent goiters), hemorrhagic linkage, 3 times, invasive cancer, 3 times. Excluding the 3 invasive cancers, the mortality was inexistant and the morbidity very low, especially without respiratory problems. Post operative complications were 2 definitive hypoparathyroidism and 1 regressive recurrential palsy (plus 2 recurrential palsy still present before the operation). The authors pointed out the good tolerance of the sternotomy which, in special case, should be absolutely preferable the cervicotomy alone, in order to reduce the operative risks, especially hemorrhagic and nervous.

Aged↗