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PubMed1989

Advanced upper airway obstruction caused by cervical goiter.

Goiters are an unusual cause of advanced upper airway obstruction. Previously described patients have been clearly symptomatic, and most have had substernal goiters. We present a patient with minimal symptoms with severe upper airway obstruction from a cervical goiter despite long-term therapy with thyroid hormone. Her spirometry exceeded criteria for urgent surgery. Patients with large goiters should have spirometry with flow-volume loop performed despite minimal or absent symptoms of respiratory distress.

Airway Obstruction↗

PubMed2006

Urgent thyroidectomy for acute airway obstruction caused by a goiter in a euthyroid pregnant woman.

Pregnancy constitutes a significant factor for thyroid enlargement. However, acute respiratory failure as a result of airway obstruction from an enlarged thyroid gland is an unusual incident. The case presented here concerns a 27-year-old black woman in her 20th gestational week who underwent an urgent operation for removal of a nontoxic, multinodular, mildly substernal goiter that was causing severe upper airway obstruction leading to acute life-threatening respiratory failure. Diagnosis of an extrathoracic tracheal stenosis was based on spirometry with analysis of the flow volume curve and was confirmed by magnetic resonance imaging of the neck. Despite operational risks to the mother as well as the fetus during gestation, an urgent thyroidectomy was carried out successfully. The postoperative period progressed normally and the patient completed her pregnancy with no further respiratory symptoms.

Adult↗

PubMed1994

Ultrasound guided biopsy of nonpalpable and difficult to palpate thyroid masses.

We reviewed our experience with ultrasound-guided biopsies of masses of the thyroid gland that were either nonpalpable or difficult to localize by palpation to evaluate the technique and correlate the results. Thirty-two biopsies were performed upon 25 patients whose clinical presentations were palpable nodule (six patients), throat discomfort (two patients), postpartial thyroidectomy follow-up evaluation (two patients), incidental discovery of a mass--by ultrasound of the neck (two patients), roentgenogram of the chest (two patients), computed tomography of the chest (one patient) and during tracheostomy placement (one patient). Other presentations were eliminate infection (one patient), odynophagia (one patient), hoarseness (one patient), cold nodule on a nuclear medicine study (one patient), hyperparathyroidism (one patient), rule out metastasis from carcinoma of the colon (one patient), persistent cough (one patient), enlarged thyroid gland (one patient) or family history of carcinoma of the thyroid gland (one patient). Fifteen patients had nuclear medicine studies showing either a cold nodule (ten patients), multinodular goiter (one patient), normal examination (two patients), hot nodule (one patient) or no thyroid gland activity (one patient). The ultrasound examinations showed either a hypoechoic nodule (25 patients), inhomogeneous or mixed echogenic nodule (six patients) or a hyperechoic nodule with hypoechoic rim (one patient). The nodules ranged in size from 3 milliliters to 7 centimeters. Twenty-six lesions were less than 3 centimeters in diameter; of the other six, four were substernal goiters. Six patients had a previous nondiagnostic biopsy directed by palpation only. Biopsy was performed using real-time ultrasound guidance with various needles. One patient had a small hematoma, which was the only complication in the study. The results of the biopsies were diagnostic in 26 of 32 patients. The final diagnosis was benign follicular cells (ten patients), adenomatous nodule (seven patients), follicular neoplasm (three patients), colloid cyst (two patients), aspergillus (two patients), fibrosis (one patient) and papillary carcinoma (one patient). Six of the biopsies yielded unsatisfactory specimens. One of the patients with a diagnosis of benign follicular cells on biopsy had a follicular carcinoma after surgical pathologic factors were obtained; that was the only false-negative result. We conclude that ultrasound-guided biopsy of the thyroid is a safe and useful method of evaluating nonpalpable and difficult to palpate thyroid masses.

Adolescent↗

PubMed1998

Thyroid reoperations: indications and risks.

Thyroid reoperations can be technically difficult and associated with an increased risk of complications. To determine the indications for reoperations and the risk of postoperative complications with these procedures, records of 362 patients undergoing thyroidectomy by a single surgeon (R.A.P.) were reviewed. Thirty-two patients had a reoperation. The group consists of 21 women and 11 men with an average age of 55 years (range, 31-79). Twenty-four patients had 1 prior operation, and 8 patients had 2 or more. We performed 4 of the initial operations, and 28 were done by surgeons at other centers. Fourteen reoperations were done for symptomatic multinodular goiter (MNG), and 5 because of a change in the histologic diagnosis from benign to cancerous. The remainder were for further treatment of malignancy. The most common operation was completion thyroidectomy (31). In 3 patients, either unilateral or bilateral modified radical neck exploration was performed. One patient required median sternotomy. One subtotal thyroidectomy was also performed. Recurrent laryngeal nerve injury occurred in 2 patients. It resolved in 1 patient but was permanent in another, who had 3 operations for MNG. One of the 2 patients with preoperative unilateral vocal cord paralysis had return of function after removal of a substernal goiter. The other had a permanent nerve injury from the original surgery. Three patients had postoperative hypocalcemia (calcium <8.0 mg/dL). This resolved in all patients within 1 to 6 months. One patient who had a third operation for MNG had postoperative hemorrhage necessitating tracheostomy for airway control. Another patient developed a seroma that resolved within 2 months. We conclude that reoperations are indicated for both benign and malignant thyroid disease. Because they carry a higher risk of complications, every effort should be made to avoid them by performing definitive initial treatment.

Female↗

PubMed1991

[Risk factors in recurrent nerve paralysis: a statistical analysis of 7566 cases of struma surgery].

Between 1979-1988, 7566 operations for benign diseases of the thyroid gland were performed. The frequency of the paresis of the recurrent nerve examined between the third and fifth postoperative day was 5.2% for patients and 3.2% for resected lobes. The incidence was correlated to performed operative procedure (enucleation, subtotal resection, lobectomy) to size (weight of specimen) and to the expansion of the goiter (substernal, intrathoracic, retrotracheal) as well as to sex. These factors influence the risk of injury with high statistic significance. The side of resection and the ligature of the thyroid inferior artery also influenced the rate of recurrent nerve pareses. Age of patient and morphology of the thyroid disease did not cause an increasing risk of nerve injury.

Adenoma↗

PubMed1995

Drains in thyroid and parathyroid surgery. Are they necessary?

OBJECTIVE: To assess the postoperative complications in patients who underwent elective thyroid or parathyroid surgery without postoperative drainage. DESIGN: During a 6-year period all patients who met study criteria were prospectively evaluated. SETTING: General community and tertiary referral center. PATIENTS: Fifty-seven patients undergoing thyroid surgery and eight patients undergoing parathyroid surgery were evaluated. Twenty-four patients were excluded because drains were placed postoperatively. Reasons for exclusion included presence of a large dead space, substernal goiter, extensive neck dissection for malignant neoplasm, and large goiters. RESULTS: Major complications consisted of a hematoma requiring reexploration in one patient, and a recurrent nerve palsy in one patient. Minor complications consisted of temporary hypocalcemia (three), seroma (one), and superior flap edema that resolved in 3 months (20). CONCLUSION: Routine prophylactic drainage in a select patient population is unnecessary after uncomplicated thyroid or parathyroid surgery.

Adult↗

PubMed1984

Follicular carcinoma of the thyroid appearing as an intraluminal superior vena cava tumor.

Follicular carcinoma of the thyroid has the propensity for microscopic angioinvasion. Tumor extension into the great veins has been previously reported primarily as a postmortem finding. Most patients have a long history of a substernal goiter and appear initially with superior vena cava syndrome. We studied a case of intraluminal invasion of the superior vena cava by a follicular carcinoma of the thyroid, without superior vena cava syndrome. To our knowledge, this is the second reported case of a patient treated successfully by surgery.

Adenocarcinoma↗

PubMed1993

Selective use of drains in thyroid surgery.

In the past, it was generally advised that every patient undergoing thyroid surgery have a drain placed because of the fear of post-operative hematoma. In the past 9 years, we have performed 400 thyroidectomies. For the first 6 years, we drained the operative site in most of thyroid procedures. However, it was apparent from our experience that drains had very little effect on the prevention of post-operative hematoma or of seroma. As a matter of fact, all four patients who required re-exploration in our initial series had drains in place. As a result of this experience over the past 3 years, during which time we have performed 150 thyroidectomies, we have used drains selectively. The indications for draining the thyroid bed have been the presence of a large dead space, operation for a large substernal goiter, and subtotal thyroidectomy for either large, multinodular goiter or for Graves' disease. Thus, among 150 recent thyroidectomies, we have drained only 35, and avoided drains in 115 patients. Though this is not a prospective study, we found no difference in the overall outcome whether drains were employed or not. Most patients who had no drains were ready for discharge within 24-48 hours of surgery. Since it may be difficult to perform a randomized prospective trial examining the use of drains in thyroid surgery, we propose that drains should be utilized only selectively for thyroid surgery.

Drainage↗

PubMed1995

Excessive Endothelial Cell Proliferation Occurring in an Organizing Thyroid Hematoma: Report of a Case and Review of the Literature.

The authors report a case of a thyroid hematoma containing an exuberant endothelial cell proliferation. No underlying vascular neoplasm was apparent and the hematoma occurred in a substernal goiter from a 90-yr-old male. Review of the literature revealed four similar previously reported cases of endothelial cell proliferation found in thyroid hematomas for a total of five cases. A fine needle aspiration or biopsy procedure antedated the definitive surgery in four patients and may be responsible for the formation of the hematoma in these cases. Areas of the endothelial proliferation resembled papillary endothelial hyperplasia (Masson's hemangioma) in four cases and cavernous hemangioma in three. However, these lesions occurred outside of vascular lumina and instead were intimately associated with fibrinous material of the hematoma. In addition, two cases contained foci of endothelial cells with nuclear atypia or intracytoplasmic lumens requiring distinction from angiosarcoma. These vigorous endothelial proliferations most likely represent alterations in the organization of a thyroid hematoma, a process similar to papillary endothelial hyperplasia, which is usually intravascular. Primary vascular neoplasms of the thyroid are exceedingly rare. Nevertheless, awareness of exuberant endothelial cell proliferation as a potential, albeit rare, manifestation of a thyroid hematoma should prompt careful attention to distinguish this reactive process from vascular neoplasms such as hemangioma or angiosarcoma.

Journal Article↗

PubMed1995

Outpatient thyroid and parathyroid surgery: a prospective study of feasibility, safety, and costs.

BACKGROUND: The purpose of this study was to determine feasibility, safety, and cost savings of outpatient thyroid and parathyroid surgery. METHODS: Consecutive unselected patients undergoing thyroid and parathyroid operations by two surgeons with a special interest in endocrine surgery were studied prospectively. RESULTS: One-hundred patients underwent operation, 61 as outpatients and 39 as inpatients. Outpatients included those undergoing thyroid lobectomy (39), total thyroidectomy (10), total thyroidectomy with parathyroidectomy (1), total thyroidectomy with modified neck dissection (1), and parathyroidectomy (10). Inpatients included those undergoing thyroid lobectomy (15), total thyroidectomy (8), total thyroidectomy with neck dissection (4), removal of substernal goiter (2), and parathyroidectomy (10). The average age of inpatients was slightly higher than that of outpatients (p < 0.05). Average hospital cost for outpatients was $1991 +/- $279 (range, $1594 to $2783) and for inpatients it was $2875 +/- 615 (range, $2031 to $4216), p < 0.001. Reasons for admission included extent of surgery (6), nausea (5), oversedation (4), urinary retention (2), inadequate home help (6), long travel time (2), patient preference (9), and medical reasons (5). No outpatients subsequently required admission. CONCLUSIONS: Outpatient thyroid and parathyroid surgery can be feasible and safe and resulted in a 30% savings in hospital costs. After extensive operations patients continue to require admission for postanesthetic complications, social reasons, or presence of serious comorbid disease.

Adult↗

PubMed2003

Prevention, evaluation, and management of complications following thyroidectomy for thyroid carcinoma.

The rate of complications during thyroid surgery has decreased because of better instrumentation, illumination, and surgical expertise. Despite these improvements, certain patients, those requiring reoperation, those with invasive cancers or with numerous nodal metastasis or recurrent tumors, and those with large substernal goiters have a low but appreciable risk for complications. When planning a thyroid operation, one should perform the operation that corrects these problems and decreases the risk for complications. Localization of at least one parathyroid gland is essential. No surgical procedure can be done, however, without a risk of complications. To decrease these possible risks the surgeon should understand the embryologic development of the thyroid and parathyroid glands, the anatomical position of key structures, and use meticulous operative technique. Experience in performing thyroid operations is essential for the best outcome with the fewest complications.

Humans↗

PubMed2006

An external support technique for the malacic trachea--treatment of tracheomalacia.

A 76-year-old woman was found to have a large, substernal, intrathoracic goiter. During excision, the trachea was found to be malacic. The trachea was sutured to a 16-mm ringed Gore-Tex (Gore & Associates, Arizona, USA) graft with Vicryl (Ethicon, Johnson & Johnson, USA) sutures. The graft was placed on the external surface of the trachea and surrounded the trachea almost 300 degrees. The patient was discharged on postoperative day seven without complications. She was seen at follow-up six months later and found to be free of complications.

Aged↗

PubMed1986

Angiomatoid carcinoma of the thyroid gland. Anaplastic carcinoma with follicular and medullary features mimicking angiosarcoma.

A 79-year-old man with a 28-year history of a substernal goiter had an anaplastic thyroid neoplasm with prominent angiomatoid features develop. Based on the light microscopic appearance of the tumor and the presence of immunocytochemical staining for Factor VIII-related antigen, a diagnosis of angiosarcoma was made. Subsequent immunocytochemical and ultrastructural studies suggested follicular and medullary differentiation without staining for Ulex europeaus I lectin or evidence of Weibel-Palade bodies. Based on these findings, the tumor is interpreted as an anaplastic carcinoma with evidence of mixed follicular and medullary differentiation and extensive intravascular growth producing an angiomatoid appearance. Positivity for Factor VII-related antigen may be due to nonspecific uptake of antigen-rich serum and platelets by the phagocytic tumor cells. Factor VIII-related antigen immunoreactivity should be interpreted with caution in intravascular neoplasms.

Adenocarcinoma↗

PubMed2004

Radionuclide imaging of the thyroid gland: patterns, pearls, and pitfalls.

Optimal thyroid scintigraphy requires an understanding of 1) the embryology, anatomy, and physiology of the thyroid gland; and 2) the properties of the 2 common imaging agents, technetium-99m pertechnetate (Tc-99m) and radioiodine (1-123). The normal gland has a characteristic scintigraphic pattern with these tracers and its uptake can be quantified with 1-123. Thyroid diseases often produce characteristic abnormal patterns. These abnormal patterns could be described as diffuse or focal, homogeneous or heterogeneous, increased or decreased. "Extrathyroidal" localization can be seen with esophageal activity, ectopic tissue, thyroglossal duct cyst, and substernal goiter. Thyroid scintigraphy of neonates, as a follow up to abnormal blood screening, demonstrates typical etiologic patterns. The first step in evaluating a patient with suspected thyroid disease is correlating the normal or abnormal scintigraphic pattern with available biochemical data, clinical history, and physical examination. By integrating the interpretive and technical "pearls" and "pitfalls" outlined in this article, the radiologist can be more confident in establishing a proper diagnosis.

Artifacts↗

PubMed2000

MR imaging of the thyroid and parathyroid glands.

Whereas scintigraphy and ultrasonography are the primary imaging modalities used for the investigation of thyroid disorders, MR imaging is generally used for specific indications, including evaluating the extent of substernal goiters, assessing the effect on adjacent structures, imaging the local extent of thyroid carcinomas, and localizing recurrent sites of thyroid neoplasia. MR imaging also has been used for the investigation of congenital disorders of the thyroid gland and the evaluation of diffuse thyroid disease, such as Grave's disease, Hashimoto's and Riedel thyroiditis, and hemochromatosis. MR imaging of the parathyroid glands is generally used for patients with recurrent or persistent hyperparathyroidism following neck exploration. MR imaging provides useful information about morphologic abnormalities of the thyroid and parathyroid glands. MR imaging has good sensitivity and positive predictive value for the identification of non-ectopic and ectopic abnormal parathyroid glands. The detailed anatomic information provided by MR imaging is useful in planning a surgical approach and is complementary to other imaging methods used in the investigation of recurrent or persistent hyperparathyroidism.

Humans↗

PubMed1999

Thoracoscopic approach to giant lymph node hyperplasia (Castleman's disease).

We describe the case of a thoracoscopic approach to giant lymph node hyperplasia (Castleman's disease) located in the mediastinum. In our patient the initial diagnosis was substernal goiter, but at cervical exploration the mass was found not to be continuous with the thyroid. The mass was easily identified through a lateral thoracoscopic approach and carefully removed. The postoperative course was uneventful, and the patient was discharged home on the fifth postoperative day. Histopathology revealed the features of Castleman's disease, mixed type. The prevalence, location, and pathogenesis of giant lymph node hyperplasia are described, together with the histology and clinical signs. Our report is proposed as the first case of an endoscopic approach to giant lymph node hyperplasia, which could be the best surgical approach for a mediastinal location.

Adult↗

PubMed2004

[Surgical treatment of thyroid carcinoma with the upper mediastinal invasion].

OBJECTIVE: To study the surgical management of the thyroid carcinoma with the upper mediastinal invasion. METHODS: Among the 560 thyroid carcinoma cases receiving surgery from 1988 to 1999, there were 10 cases of the upper mediastinal, the 10 cases were retrospectively analyzed for their preoperative diagnosis, surgical methods and postoperative complications. RESULTS: The upper mediastinal invasion rate of the 560 cases was 1.9% (10/516). There are three paths for the upper mediastinal invasion: (1) Trachea esophagus groove and upper mediastinal lymphatic node metastasis. (2) Tumor direct invasion. (3) Primary malignant substernal goiter. Operative methods include: (1) Tumor removal without using sternum incision. (2) Tumor removal with sternotomy. (3) Extension operation with sternum or/and clavicle bones removal. The number of those cases who survived 1, 3, 5, 10 years were 10, 8, 6, 4 respectively. Radical removal of tumors was achieved in 9 cases. The complications occurred were: 2 cases of chylous fistula; 2 cases of vocal paralysis; 1 case of thyrocervical trunk artery bleeding; 1 case of phrenic nerve paralysis; 1 case of pneumothorax. CONCLUSIONS: Surgery can be adopted for treating thyroid carcinoma with the upper mediastinal invasion, and it can have a good long-term prognosis.

Aged↗

PubMed2005

[Specialization in thyroid surgery].

OBJECTIVE: To evaluate the results of surgically treated patients with benign thyroid disorders from Department of Otolaryngology- Head and Neck Surgery. METHODS: The clinical data of 496 patients operated for benign thyroid disorders were retrospectively analyzed in this department from January 2001 to April 2004. The incidence of complications, particularly postoperative permanent recurrent laryngeal nerve palsy and hypocalcemia, duration of surgery, incision length on the neck, hospitalization days and postoperative recurrence were evaluated. RESULTS: Unilateral total thyroidectomy with contralateral partial lobectomy was performed in 314 cases, unilateral total thyroidectomy with isthmectomy in 76, bilateral subtotal thyroidectomy with the remnant left at the upper pole in 29, isthmectomy in 3, total thyroidectomy in 46. The operations on 28 patients with substernal goiter have been successfully performed via cervical collar incision. Of these patients, the incidences of unilateral recurrent laryngeal nerve paralysis and temporary postoperative hypocalcemia were 0.2% (1/496) and 1.8% (9/496), respectively. There were no bilateral vocal cord paralyses and permanent hypocalcaemia. Postoperative hemorrhage requiring reoperation occurred in 3 cases (0.6%). No patients had incision infection. The mean duration of surgery was 66 min. The mean incision length on the neck was 5.2 cm. The incidence of postoperative recurrence was 0.2% (1/496). The mean hospitalization day was 6.3 d. CONCLUSIONS: Otolaryngologists who had received stringent training of head and neck surgery seem to have the advantage to avoid injury of recurrent nerve in the thyroid surgery.

Adult↗