Search

Sternotomy is indicated when a goiter cannot be resected via a cervical incision, such as in the case of a substernal goiter extending beyond the aortic arch. In this article, we report a case of a large substernal goiter that was successfully removed using the cervical approach only. This is a case of a 68-year-old woman, diagnosed with goiter 20 years ago, who complained of a neck mass enlargement with associated cough. Pathological examination revealed no malignancy. Computed tomography (CT) scan showed an 11-cm thyroid mass reaching the level of the aortic arch. Preoperatively, we evaluated the substernal extent of the goiter via CT in the extended neck position to decide whether sternotomy was necessary. With the patient’s neck extended, the goiter withdraws cranially above the aortic arch. The mass was then removed via the cervical approach without sternotomy. Preoperative CT in the extended neck position was thus deemed helpful in deciding whether or not sternotomy was required.

We report a patient with right substernal goiter and preoperative vocal cord palsy (VCP). During dissection, an anatomic variation of the recurrent laryngeal nerve (RLN) and a prolonged EMG were detected by intraoperative neuromonitoring (IONM). Symmetrical vocal cord movement was recorded one month after surgery. The potential for recovery of vocal cord function is high after surgical treatment of a thyroid tumor with preoperative VCP. An IONM enables early localization of the RLN position. To the best of our knowledge, this case of prolonged EMG in an abnormal acquired-ventral RLN trajectory is the first reported in the literature.

Jehovah’s Witnesses present a unique challenge in oral and head and neck surgery. We report a case of a substernal goiter excised on a Jehovah’s Witness without the use of blood transfusion, in accordance with the patient’s beliefs. Additionally, we review the literature on the care of this patient population, focusing on preoperative optimization, perioperative management, and postoperative care.

Since substernal goiter first being described by Haller in 1749, a consensus on the definition of this entity has not been ensured, yet. Despite substernal goiter or retrosternal goiter is delineated as an enlarged thyroid gland with a component extending into the mediastinum, at least 10 definitions have described being able to depict the most accurate definition for substernal goiter. Of note, no consensus still has been declared on the therapeutic management of asymptomatic substernal goiter. It should be pointed out that, the American Association of Endocrine Surgeons (AAES), Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults reported approximately 9% to 13% of substernal goiters are being harbored thyroid malignancy. The following vignette case describes the clinical features of a symptomatic substernal goiter with chronic lymphocytic thyroiditis, her treatment by sutureless total thyroidectomy with intermittent-intraoperative neural monitoring (I-IONM), and the energy-based device without sternotomy, and the response of an adult who presented with a family history of malignant histopathology, differentiated thyroid carcinoma, which was exposed to the postoperative radioactive iodine ablation. We may recommend dividing the branches of superior thyroid arteries and the superior thyroid veins individually and exploring the fibrous Ligament of Berry, the true Ligament of Berry, with its safe interrelation to the inferior laryngeal nerve, finically, which may be regarded as different peas in a pod in a complete sutureless thyroidectomy for substernal goiter with thyroiditis in thyroidology.

Objective The aim of this study was to validate the predictors of peropertive computed tomography imaging parameters for sternotomy in patients with substernal goiter.Methods We retrospectively reviewed complete clinical and computed tomography data of 37 patients who had substernal goiter and underwent surgery from January 2010 to February 2019. The patients were divided into two groups based on whether or not underwent sternotomy surgery. The maximum length and width, length behind sternum of tumors were measured on preoperative computed tomography images, the volume above and below sternum, and total volume of tumors was calculated. Logstic regression model and receiver operating characteristic curve analysis were performed to identify siginificant predictors associated with sternotomy.Results Out of a total of 37 patients, 4 patients (10.8%) underwent sternotomy. The length, width and length behind sternum, as well as the volume below sternum and the total volume of tumors were significantly greater in patients with sternotomy compared to those without sternotomy (all PConclusion Computed tomography examination plays an important role in determining the surgery need for substernal goiter. The length behind sternum of tumor is a convenient and independent predictor of sternotomy for substernal goiter.

Objective(s): To review the experience of 3 hospitals with airway management during surgery for substernal goiter and identify preoperative factors that predict the need for advanced airway management techniques. Methods: A retrospective chart review between 2009 and 2017 of patients with substernal goiter treated surgically at 1 of 3 hospitals was performed. Results: Of the 179 patients included in the study, 114 (63.7%) were female, the mean age was 55.1 years (range 20-87). Direct laryngoscopy or videolaryngoscopy was successful in 162 patients (90.5%), with fiberoptic intubation used for the remaining 17 patients. Thirty-one patients (17.4%) required >1 intubation attempt; these patients had larger thyroids (201.3 g, 95% CI 155.3-247.2 g) than those intubated with 1 attempt (144.7 g, 95% CI 127.4-161.9 g, P = .009). Those who required >1 attempt had higher BMI (38.3, 95% CI 34.0-42.6 vs. 32.9, 95% CI 31.5-34.3, P = .02). Mallampati score was found to be a predictor of >1 attempt, though tracheal compression and tracheal shift were not found to be predictors of >1 attempt, nor was the lowest thyroid extent. BMI was the only independent factor on multivariable logistic regression of needing >1 attempt (odds ratio 1.056, 95% CI 1.011-1.103, P = .015). Conclusions: The majority of patients undergoing surgery for substernal goiter can be intubated routinely without the need for fiberoptic intubation. Thyroid-specific factors such as lowest thyroid extent and mass effect of the gland on the trachea do not appear to be associated with difficult intubation, whereas classic patient factors associated with difficulty intubation are. Level of evidence: VI

Goiter with an intrathoracic component is relatively common; however, it is less common to see extent outside the anterior or posterior mediastinum. We present a case of intrathoracic goiter of significant size and abnormal placement which is examined using both 99mTc-pertechnetate and iodine-123 single-photon emission computed tomography/computed tomography.

Substernal goiter is an enlarged thyroid gland, harboring a component extending into the mediastinum. Surgical management requires genuine and rigorous preoperative planning as physicians could encounter the prospect of the gland coming into close quarters with the vital intrathoracic structures. The neck and chest multiplanar cross-sectional imaging provide essentialness of an extracervical approach for the procedure. In the present study, a 57-year-old female who admitted with the intermittent dyspnea and dysphagia with a huge goiter is reported. The labs were reported within the normal limits and the video laryngoscopy displayed no pathologic finding. Her neck sonography revealed the multiple nodules within the gland, without determining the most proximal border of the left lobe. The neck and chest computed tomography depicted a substernal goiter harboring the left lobe, extending till the left innominate vein and a sutureless total thyroidectomy by the collar incision without a median sternotomy was performed. We would recommend sutureless thyroidectomy for substernal goiter just considering to divide meticulously the superior thyroid arteries and veins separately and exploring the fibrous Ligament of Berry, that is, the true Ligament of Berry, with its safe relationship to the recurrent laryngeal nerve in Thyroidology.

Asian Medical Journal and Alternative Medicine, 21, 1, 55

Introduction: Goiter is abnormal growth of the thyroid gland. When goiter extends into the mediastinum it is called retrosternal or substernal. Substernal goiter can cause compression of the great vessels, trachea, and esophagus. When it compresses trachea it can result in airway obstruction. In that case treatment of choice is thyroidectomy and Radio Iodine Ablation (RIA). But some patients are considered to be high risk for operation due to multiple comorbidities. We are presenting this case where we tried experimental therapy with airway stent and external beam radiation. Case: An 81 year old female presented to the hospital complaining of chest pain. She also reported dysphagia to solids and liquids and weight loss during one month. Past medical history included congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease with home oxygen support. On physical exam thyroid was palpable to the level of sternal notch. Arterial blood gases showed hypoxemia (PO2 63), thyroid function tests showed an abnormally suppressed TSH (

Background: When compared to removal of cervical goiters, patients undergoing removal of substernal goiter have been found to have higher rates of complications, including recurrent laryngeal nerve injury, bleeding, and hypoparathyroidism. Previous literature has discussed hemithyroidectomy versus total thyroidectomy for cervical goiters showing that the less invasive procedure was a reasonable option with decreased morbidity overall.

Substernal thyroid goiters that require surgery may pose unique challenges to thyroid surgeons based on the size and inferior extent of the disease. Consequently, there are multiple variations to the approach and additional considerations in operative planning and technique that are often required. Although there is some debate on the precise definition of substernal thyroid, for the purposes of this article it is considered to be thyroid tissue below the sternal notch or clavicle. This article aims to provide thyroid surgeons who encounter the challenges of substernal thyroid a straightforward algorithm for planning and operative techniques that have proven successful in the safe and effective management of this condition.

Substernal goiter is defined as a thyroid growth beyond the thoracic inlet. Using the cross-section imaging CT system, it can be classified into three grades. The aim of the study was to validate the surgical approach and the occurrence of postoperative complications with substernal goiter extension in our patient population. From a total of 1145 patients who underwent thyroid surgery at our institution in a 15-year period, 60 patients with substernal goiter were included. Clinical features and demographics, degree of extension, surgical details, and complications were analyzed. Mean ± SD age of the patients was 58 ± 14.7 years and 88 per cent were females. According to the cross-section imaging CT system 61.7 per cent were grade I,23.3 per cent grade II, and 15 per cent grade III. Total thyroidectomy was performed in 78.3 per cent of the patients, subtotal thyroidectomy in 18.3 per cent, and lobectomy in 3.3 per cent. The cervical approach was sufficient to perform 96.7 per cent of the thyroidectomies, requiring partial sternotomy in only two patients with grade III substernal goiter. Patients with grade III substernal goiter had a higher risk for postoperative dysphonia (OR = 14.29, IC95% 1.14-178.9, P = 0.03), which occurred in three patients (two transient and one permanent). Transitory hypoparathyroidism was present in 20 patients (33.3%) and did not correlate with goiter extension. Most substernal goiters can be resected through a cervical approach, with relatively low morbidity. Postoperative dysphonia was directly related to the extension of the goiter. Few cases with grade III goiters require a partial sternotomy.

症例は₆₉歳女性．バセドウ病のためメルカゾール内服治療中，甲状腺左葉から縦隔内に伸展する巨大な縦隔内甲状腺腫を認めた．造影CTでは甲状腺左葉下極から縦隔内に伸展する腫瘍を認め，下端は大動脈弓に達していた．気管・食道は右方偏位していたが明らかな浸潤所見はみられなかった．穿刺吸引細胞診は良性．頸部操作のみで切除できない場合に備え胸骨縦切開も考慮した状態で手術を開始した．バセドウ病を合併していたことから術式は甲状腺全摘術とした．縦隔内甲状腺腫は周囲との癒着や浸潤を認めず、比較的容易に創外に脱転することができたため，胸骨縦切開は不要であった．術後経過は良好で，術後₇ 日目に退院となった．今回，巨大縦隔内甲状腺腫を頸部創のみで切除可能であった症例を経験した．文献的考察も加えて報告する．

Surgery for substernal goiters can be technically demanding. Extensive mediastinal extension brings the thyroid gland into close quarters with vital intrathoracic structures. Proper preoperative planning is required to determine the potential need for an extracervical approach. Assessing the risk of requiring an extracervical approach is typically based on findings from cross-sectional imaging of the neck and chest. This article addresses the important anatomical considerations when resecting a large substernal goiter, and also reviews various extracervical approaches.

Highlights • Substernal goiter definition is controversial, while they are generally defined as goiters which at least 50% of the thyroid mass extends bellow the thoracic inlet. • Our patient had a massive substernal multinodular goiter, the left lobe of which caused compression of the braciocephalic vein with symptoms from his left upper extremity. • The massive size of the gland along with the strict adhesion of the isthmus and left thyroid lobe to the brachiocephalic vein led to the decision of performing a median sternotomy. • Despite the extensive procedure, patient recovery was uneventful. • The lack of a uniform definition on substernal goiter and the diversity of thoracotomy indications, lead to a patient-tailored surgical approach. Still the execution of thoracotomy is considered safe in the hands of an experienced surgeon., Introduction Substernal goiters are characterized by the protrusion of at least 50% of the thyroid mass below the level of the thoracic inlet. Still their definition is controversial. Case presentation The case refers to a 44 year old male who presented to our department due to swelling and a feeling of ‘heaviness’ of his left upper extremity for the past 6 months. CT scan revealed a massive substernal goiter extending to the great vessels. Intraoperatively, a median sternotomy was performed due to the size of the gland and the close adhesion of the isthmus and lower left thyroid lobe to the brachiocephalic vein. Resection of the gland revealed the vein to have a cord-like shape, leading to reduced venous return and upper extremity symptoms. Recovery was uneventful for the patient who was discharged on the 7th postoperative day. Discussion While most substernal goiters can be surgically managed through a cervical incision, there are cases in which a median sternotomy is indicated. Those cases include excessive gland size, thoracic pain, ectopic thyroid tissue and the extent of the goiter to the aortic arch. Median sternotomy is associated with a number of intra and postoperative complications, although when performed by an experienced surgeon, mortality and morbidity rates along with long-term recovery are not affected. Conclussion The lack of a uniform definition and variety of indications, lead to a patient-tailored approach regarding the execution of sternotomy during surgical management of massive substernal goiters.

Aldo Bove, Raffaella Maria Di Renzo, Gauro D’Urbano, Manuela Bellobono, Vincenzo D’ Addetta, Alfonso Lapergola, Giuseppe Bongarzoni Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” Chieti-Pescara, Chieti Scalo, Italy Abstract: The definition of substernal goiter (SG) is based on variable criteria leading to a considerable variation in the reported incidence (from 0.2% to 45%). The peri- and postoperative complications are higher in total thyroidectomy (TT) for SG than that for cervical goiter. The aim of this study was to evaluate the preoperative risk factors associated with postoperative complications. From 2002 to 2014, 142 (8.5%; 98 women and 44 men) of the 1690 patients who underwent TT had a SG. We retrospectively evaluated the following parameters: sex, age, histology, pre- and retrovascular position, recurrence, and extension beyond the carina. These parameters were then related to the postoperative complications: seroma/hematoma, transient and permanent hypocalcemia, transient and permanent laryngeal nerve palsy, and the length of surgery. The results were further compared with a control group of 120 patients operated on in the same period with TT for cervical goiter. All but two procedures were terminated via cervicotomy, where partial sternotomies were required. No perioperative mortality was observed. Results of the statistical analysis (Student’s t-test and Fisher’s exact test) indicated an association between recurrence and extension beyond the carina with all postoperative complications. The group that underwent TT of SG showed a statistically significant higher risk for transient hypocalcemia (relative risk =1.767 with 95% confidence interval: 1.131–2.7605, P=0.0124, and need to treat =7.1) and a trend toward significance for transient recurrent laryngeal nerve palsy (relative risk =6.7806 with 95% confidence interval: 0.8577–53.2898, P=0.0696, and need to treat =20.8) compared to the group that underwent TT of cervical goiter. TT is the procedure to perform in SG even if the incidence of complications is higher than for cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina. In the presence of these factors, greater care should be taken. Keywords: substernal goiter, total thyroidectomy, complications

Aldo Bove, Raffaella Maria Di Renzo, Gauro D’Urbano, Manuela Bellobono, Vincenzo D’ Addetta, Alfonso Lapergola, Giuseppe Bongarzoni Department of Medicine, Dentistry and Biotechnology, University “G. d’Annunzio” Chieti-Pescara, Chieti Scalo, Italy Abstract: The definition of substernal goiter (SG) is based on variable criteria leading to a considerable variation in the reported incidence (from 0.2% to 45%). The peri- and postoperative complications are higher in total thyroidectomy (TT) for SG than that for cervical goiter. The aim of this study was to evaluate the preoperative risk factors associated with postoperative complications. From 2002 to 2014, 142 (8.5%; 98 women and 44 men) of the 1690 patients who underwent TT had a SG. We retrospectively evaluated the following parameters: sex, age, histology, pre- and retrovascular position, recurrence, and extension beyond the carina. These parameters were then related to the postoperative complications: seroma/hematoma, transient and permanent hypocalcemia, transient and permanent laryngeal nerve palsy, and the length of surgery. The results were further compared with a control group of 120 patients operated on in the same period with TT for cervical goiter. All but two procedures were terminated via cervicotomy, where partial sternotomies were required. No perioperative mortality was observed. Results of the statistical analysis (Student’s t-test and Fisher’s exact test) indicated an association between recurrence and extension beyond the carina with all postoperative complications. The group that underwent TT of SG showed a statistically significant higher risk for transient hypocalcemia (relative risk =1.767 with 95% confidence interval: 1.131–2.7605, P=0.0124, and need to treat =7.1) and a trend toward significance for transient recurrent laryngeal nerve palsy (relative risk =6.7806 with 95% confidence interval: 0.8577–53.2898, P=0.0696, and need to treat =20.8) compared to the group that underwent TT of cervical goiter. TT is the procedure to perform in SG even if the incidence of complications is higher than for cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina. In the presence of these factors, greater care should be taken. Keywords: substernal goiter, total thyroidectomy, complications

Introduction Goiter is localized or generalized thyroid hypertrophy. It is usually cervical, but may show intra-thoracic development beyond the thoracic inlet and down to the mediastinum: i.e., substernal goiter. The purpose of this study was to analyze the epidemiological, clinical and paraclinical profile of substernal goiter and the difficulties of management. Material and methods A retrospective study included 50 cases from our ENT department. Results Mean age was 47 years, with a sex ratio of 0.06. Clinical symptomatology was dominated by medial anterior cervical swelling. Compression signs were observed in 26 patients, and cervical lymph nodes in 3. Mean time to consultation was 7 years. Fiberoptic endoscopy found vocal cord palsy in 3 patients. Cervical ultrasonography was the first-line diagnostic test. Cervical-thoracic CT scan was requested in 45 patients to study thoracic extension and the relation of the thyroid mass with the supra-aortic vascular axes. Treatment systematically comprised total thyroidectomy on a cervical approach. There were 6 cases of malignancy. Discussion-conclusion Substernal goitre is fairly frequent. Despite particularities, an exclusively cervical approach is sufficient in a large majority of cases. The substernal nature of the goitre did not have major impact on postoperative complications.

The definition of substernal goiter (SG) is based on variable criteria, leading to considerable variations in the reported incidence (from 0.2% to 45%). The peri- and postoperative complications are higher in total thyroidectomy (TT) for SG than that for cervical goiter. This study aimed to evaluate the preoperative risk factors associated with postoperative complications. From 2002 to 2014, 142 (8.5%; 98 women and 44 men) of the 1690 patients who underwent TT had a SG. We retrospectively evaluated the following parameters: sex, age, histology, pre- and retro-vascular position, recurrence, and extension beyond the carina. These parameters were then related to the postoperative complications: seroma/hematoma, transient and permanent hypocalcemia, transient and permanent laryngeal nerve palsy, and the length of surgery. The results were further compared with a control group of 120 patients operated on in the same period with TT for cervical goiter (CG). Statistical analysis (Student t test and Fisher exact test) indicated an association between recurrence and extension beyond the carina with all postoperative complications. The group that underwent TT of SG showed a statistically significant higher risk for transient hypocalcemia (relative risk = 1.767 with 95% confidence interval: 1.131–2.7605, P = .0124, and need to treat = 7.1) and a trend toward significance for transient recurrent laryngeal nerve palsy (relative risk = 6.7806 with 95% confidence interval: 0.8577–53.2898, P = .0696, and need to treat = 20.8) compared with the group that underwent TT of cervical goiter. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina. TT is the procedure to perform in SG even if the incidence of complications is higher than cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina.

OBJECTIVES To preliminarily evaluate the safety, effectiveness, and feasibility of microwave ablation (MWA) for substernal goiter (SSG) in select patients and to provide a relevant treatment reference for further studies. METHODS From April 2017 to December 2017, 10 patients with SSG were treated by MWA. All patients were followed for at least 3 months to observe the therapeutic effects and complications. Therapeutic effects were assessed at follow-up for the relief of patients' symptoms, resolution of the cosmetic grade, and volume reduction rate (VRR) of SSG. Possibly related factors for the 3-month VRR of the nodules were analyzed. RESULTS The study included 9 female patients and 1 male patient with a mean age ± SD of 56.8 ± 10.1 years (range, 34-70 years). The mean volume of the nodules was 52.9 ± 27.9 mL (range, 23.7-122.6 mL). The nodule volume was significantly reduced at the 3-month follow-up (17.5 ± 9.5 mL; P

BackgroundSternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach to thyroidectomy. We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG and analyzed the preoperative and postoperative characteristics of patients with SSG compared with those with large goiters contained entirely within the neck or a cervical goiter.MethodsA retrospective review of a surgical database was performed. We included patients with large (>100g) thyroids or SSG, regardless of size. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had an SSG and patients who had a cervical goiter with particular focus on those who required sternotomy.ResultsOf the 220 patients, 127 patients (58%) had SSG, of whom 7 (5.5%) required sternotomy. All patients who underwent sternotomy underwent preoperative computed tomography scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints and have extension of the thyroid gland below the aortic arch. Sternotomy took an average of 2hours longer than a cervical incision, was associated with significantly more blood loss (600 versus 190mL, P=0.04), and a longer length of stay (3.1 versus 1.8d, P=0.03) than cervical thyroidectomy.ConclusionsSternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch and were more likely to present complaining of chest pressure and voice issues.

Missed gland is an extremely rare condition. It is a mediastinal thyroid mass found after total thyroidectomy. We report a case of missed gland. The patient underwent total thyroidectomy due to multinodular goiter and thyroid stimulating hormone levels did not increase after surgery. Pathological tests revealed a micropapillary carcinoma. Thyroid ultrasonography and scintigraphy scan revealed mediastinal thyroid mass. The patient underwent redo surgery without sternotomy and there was no morbidity after the second surgical procedure. Most missed thyroid gland cases are due to incomplete removal of plunging thyroid goiter during total thyroidectomy. They also can be attributed to a concomitant, unrecognized mediastinal goiter, which is not connected to the thyroid gland with vessels or a thin fibrous band. It should be noted that absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray does not exclude substernal goiter. The presence of a missed thyroid gland should be kept in mind when postoperative thyroid stimulating hormone levels remain unchanged.

Most substernal goiters can be managed through the transcervical approach, but a sternotomy is required in some cases. This report is about a large substernal goiter, which was resected via a transcervical and full sternotomy approach. The patient was a 57-year-old female, who visited our hospital for surgical treatment for a large substernal goiter. Computed tomography of the neck and chest revealed that the substernal goiter extended to both sides of the thorax and had compressed the trachea. We performed total thyroidectomy safely via a transcervical and full sternotomy approach. No postoperative complications occurred, except transient hypocalcemia. A histopathological examination did not reveal any malignancy, and the lesion was diagnosed as an adenomatous goiter. Most substernal goiters can be managed through the transcervical approach, but a full sternotomy is required when a substernal goiter extends to both sides of the thorax and/or has a larger diameter than the thoracic inlet or airway constriction is revealed. A full sternotomy provides excellent exposure and can help reduce the risk of complications, such as recurrent laryngeal nerve palsy and injuries to major blood vessels.

Objective This study aims to compare the prevalence of laryngopharyngeal reflux signs between two groups of patients undergoing thyroidectomy for voluminous goiter: substernal goiters and voluminous cervical goiter without thoracic extension. Subjects and methods A retrospective case-control study was performed with data retrieved of the charts of the patients submitted to thyroidectomies occurred at a tertiary care center (Head and Neck Surgery Department, University of São Paulo Medical School) between 2010 and 2014. The selected thyroidectomies were allocated in two groups for study: patients with substernal goiters and patients with voluminous cervical goiter without thoracic extension. Cervical goiters were selected by ultrasonography mensuration. Clinical criterion was used to define substernal goiter. Results The average thyroid volume in patients with substernal goiter was significantly greater than the average volume in patients with only cervical goiter (p < 0.001). The prevalence of signs of reflux laryngitis at laryngoscopy was significantly greater in substernal goiter patients (p = 0.036). Moreover, substernal goiter was considered as the unique independent variable for high reflux laryngitis signs at laryngoscopy (OR = 2.75; CI95%: 1.05-7.20; p = 0.039) when compared to only cervical goiter patients. Conclusion This study shows a significant association between substernal goiters and signs of laryngopharyngeal reflux at preoperative laryngoscopy. Therefore, when compared with voluminous cervical goiters, the substernal goiters increase the chance of reflux laryngitis signs in patients.

The aim of this retrospective multicenter study was to verify whether the substernal goiter and the type of surgical access could be risk factors for recurrent laryngeal nerve palsy during total thyroidectomy. Between 1999-2008, 14,993 patients underwent total thyroidectomy. Patients were divided into three groups: group A (control; n=14.200, 94.7%), cervical goiters treated through collar incision; group B (n=743, 5.0%) substernal goiters treated by cervical approach; group C (n=50, 0.3%) in which a manubriotomy was performed. Transient and permanent unilateral palsy occurred significantly more frequently in B+C vs. A (P≤.001) and in B vs. A (P≤.001). Transient bilateral palsy was significantly more frequent in B+C vs. A (P≤.043) and in C vs. A (P≤.016). Permanent bilateral palsy was significantly more frequent in B+C vs. A (P≤.041), and in B vs. A (P≤.037). Extension of the goiter into the mediastinum was associated to increased risk of recurrent nerve palsy during total thyroidectomy.

We report a case of a female patient aged 46 years with a history of nodular goiter for which she had a subtotal thyroidectomy 31 years ago. She was referred to the emergency department of our hospital because of dyspnea and chest pain for 20 days, then developed cyanosis and edema of the head and upper extremities. Chest X-ray revealed tracheal repulsion. Cervical and thoracic computed tomography showed a giant solid and a cystic mass in the anterior mediastinum and bilateral pleural effusion. The neck ultrasound did not show any thyroid masses. An exploratory thoracotomy with extensive resection considering the anatomical relation of the mass and the adjacent structures was planned. Immediately after the operation, the patient developed airway complications that resolved in 7 days. The tumor was confirmed pathologically as nodular goiter. The overall outcome of the patient was positive; she is healthy after more than 12 months of follow-up. This report examines the approach to diagnosis and management of one of the most common surgical complication associated with substernal goiters.

A 75-year-old woman with a longstanding history of a substernal thyroid goiter presented with acute shortness of breath, and she was intubated due to respiratory distress. Computed tomography (CT) scan revealed a compressive substernal goiter with associated vascular compression, axillosubclavian thrombosis, and saddle pulmonary embolism. Weight-based heparin was immediately administered, and the patient subsequently underwent successful thyroidectomy via a cervical incision. This case report of a rare saddle pulmonary embolism associated with a substernal thyroid goiter underscores the importance of early elective thyroidectomy. Successful management of these potentially devastating pulmonary emboli (PE) associated with large substernal goiters is possible. How to cite this article Nelson DW, LoPinto M, Sidani C, Lew JI. Large Substernal Thyroid Goiter Associated with Saddle Pulmonary Embolism. World J Endoc Surg 2016;8(3):214-216.

We report a case of intrathoracic goiter with positive Pemberton sign. Conventional spirometry did not show abnormalities, but arm elevation spirometry with flow-volume loops revealed expiratory flow limitation with a plateau. Clinicians should consider repeating flow-volume loops with arm elevation in all cases of intrathoracic goiter with initially normal loops.

Absztrakt Bevezetés: A megnagyobbodott, akár a tracheát is komprimáló pajzsmirigy műtéti kezelése legtöbb esetben a totális thyreoidectomia, amely mind a fej-nyak sebészek, mind az általános sebészek körében ismert eljárás. A megnagyobbodott pajzsmirigy az esetek körülbelül 1–10%-ában a szegycsont mögé ér, ezáltal eltérő műtéti technikát igényel az eltávolítása. Betegek és módszerek: Munkacsoportunk 2000–2014-ig 182 substernalis struma miatt végzett műtétet. Substernalisnak azon pajzsmirigylebenyeket tekintettük, amelyek legalább a jugulum szintje alá értek. Retrospektíve vizsgáltuk a 182 esetet, amelyek substernalisan elhelyezkedő pajzsmirigylebenyek miatt kerültek műtétre az elmúlt 14évben. Eredmények: Minden beteg panaszokkal érkezett, amelyek közül a fulladás és nehézlégzés volt a leggyakoribb. A műtétet minden esetben megelőzte képalkotó vizsgálat. 31 esetben praeoperativ nyaki ultrahang készült, 13 esetben MR- és 138 esetben CT-vizsgálat jelentette a képalkotó eljárást. 15 beteg esetében történt korábban részleges vagy teljes pajzsmirigylebeny-eltávolítás. Nyaki metszésből 175 esetben sikerült eltávolítani a megnagyobbodott lebenyeket, median sternotomiára hét esetben kényszerültünk. Átmeneti nervus laryngeus recurrens bénulás egy esetben, végleges pedig három esetben fordult elő. Kilenc esetben igazolódott rosszindulatú pajzsmirigy-megbetegedés a specimenből, 173 esetben benignus megnagyobbodásról volt szó. Következtetés: Fulladás és nehézlégzés a leggyakoribb panasz a nagymértékben megnövekedett, sternum mögé is érő, úgynevezett substernalis vagy retrosternalis struma kórképében. A CT-vizsgálat alapvető a diagnosztikában, hiszen a pontos kiterjedés meghatározása egyik alapfeltétele a megfelelő sebészi kezelésnek, illetve az operáló team összeállításának. A megfelelő kezelés a műtét, azonban sok esetben a műtét során más technika alkalmazása válik szükségessé, mint a hagyományos, nyakról is könnyen kivehető kisebb méretű pajzsmirigylebenyek eltávolításakor. Ezért fontos a mellkassebészeti háttér vagy aktív részvétel ezen beavatkozásokban. A hazai irodalmat áttekintve nem találtunk ekkora betegcsoportot vizsgáló összefoglaló közleményt.

The presence of substernal goiter is, per se, an indication for surgical management. Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The aim of this study was to identify the preoperative predictors of a sternotomy in the management of substernal goiter in order to provide better preoperative planning and patient consent. Between 2005 and 2012, 665 patients were referred to our clinic for thyroidectomy, 42 patients (6.3%) had substernal goiter and were included in this study. All substernal goiters were treated surgically, 38 (90.5%) by a cervical approach and 4 (9.5%) by full median sternotomy. All surgeries were successful, with no major postoperative complications. Minor postoperative complications of transient hypocalcemia and transient paralysis of the recurrent laryngeal nerve occurred in 5 (11.9%) and 2 (4.7%) cases, respectively. Indication of median sternotomy was as follows: extension of goiter below the aortic arch, large thyroid tissue extending towards tracheal bifurcation, and ectopic thyroid tissue in the mediastinum. Substernal goiter can be removed through a cervical incision, but on rare occasions, a median sternotomy may be required.

Purpose: The purpose of this study was to evaluate the clinical and surgical differences between substernal goiter and non substernal goiter according to institutional experience. Material and Method: Twenty-nine patients with substernal goiter and 62 randomly chosen non substernal goiter patients from January 2009 to October 2012 were compared retrospectively according to their pre-operative and post-operative data. Cervical approached total thyroidectomy was applied to patients with substernal goiter. Results: Thirteen of twenty-nine substernal goiter patients were male (44.8%) and 16 were female (55.2%). Body mass index, age, gender in both groups were compared and found to be similar. No post-operative complication was observed. Pathology results revealed malignancy in 24.1% of patients. Discussion: Patients with substernal goiter can be safely treated through the cervical approach with low complication rates in expert hands. Turk Jem 2013; 17: 116-20

Introduction: We present a rare case of chylothorax associated with an intrathoracic goiter in Graves’ disease that was treated with radioactive iodine. Case Report: A 23-year-old woman with Graves’ disease was referred to our clinic with a pleural effusion, dyspnea, characteristic bilateral proptosis, and a diffuse goiter. The pleural fluid biochemistry was consistent with chylothorax. However, the chylothorax did not decrease with conservative therapy. Therefore, RAI was administered. Subsequently, the chylothorax and goiter improved more quickly than expected. Conclusions: This case illustrates that chylothorax associated with a substernal goiter in Graves’ disease can be treated successfully with radioactive iodine instead of surgery.

SummarySubsternal goiter can be classified as primary or secondary, depending on the site of origin. Primary substernal goiters (< 1% of substernal goiters), also known as mediastinal aberrant goiters, arise from ectopic thyroid tissue in the mediastinum, and receive their blood supply from intrathoracic arteries instead of thyroid arteries. A secondary substernal goiter is defined as one that has descended from the neck to the plane below the thoracic inlet, or one that has more than 50% of its mass lying inferior to the thoracic inlet. Surgical resection should be considered even for elderly patients because of the risks of mass compression symptoms (e.g., dyspnea and dysphasia), malignancy, and low morbidity of surgery. Most of the primary substernal goiters can be resected through the cervical approach. In most instances, sternotomy or thoracotomy is needed only in cases of previous cervical thyroidectomy, invasive carcinoma, or ectopic goiter.

O bócio mergulhante é uma patologia relativamente rara e estima-se que corresponda a 7% de todos os casos de bócio. Na maioria dos doentes é assintomático (sendo detetado de forma acidental), mas pode produzir sintomas decorrentes da compressão de estruturas contíguas. Os autores apresentam o caso de uma doente de 89 anos, com antecedentes pessoais de bócio, admitida no Serviço de Urgência (sala de emergência) por quadro de dificuldade respiratória com estridor. A avaliação efetuada foi compatível com volumoso bócio mergulhante com desvio e deformidade da traqueia, apresentando avaliação analítica a revelar hipertiroidismo. O caso foi discutido com a equipa de Cirurgia Endocrinológica, tendo a doente sido submetida a tiroidectomia total. Com este caso salienta-se a importância da rápida integração dos dados da anamnese em conjunto com o exame objetivo na abordagem a um doente na sala de emergência. Substernal goiter is a relatively rare condition and is estimated to correspond to 7% of all cases of goiter. In most cases it is asymptomatic (being accidentally detected), but may produce symptons resulting from the compression of contiguous structures. The authors present the case of a 89 year-old woman, with personal history of goiter, admitted in the Emergency Department (emergency room) due to respiratory distress with stridor. The evaluation was compatible with large substernal goiter with deviation and tracheal deformity, presenting an analytical evaluation revealing with hyperthyroidism. The case was discussed with Endocrinologic Surgery medical team and the patient was submitted to total thyroidectomy. This case emphasizes the importance of the rapid integration of data from anamnesis and examination in the approach to a patient in the emergency room.

BACKGROUND AND OBJECTIVE: The substernal goiter is a condition in which more than 50% of thyroid gland extended to the mediastinum. In this study the clinical symptoms, diagnosis, treatment and the surgical complications in 22 patients were assessed.METHODS: In this cross-sectional study the recorded files of all patients who went under thyroidectomy operation in Shahid Beheshti and Yahyanejad hospitals in recent 15 years (from 1994 to 2009) were assessed. Twenty six patients had substernal thyroid and their age, sex, pathology, symptoms, method of thyroidectomy, the postoperation complications, mortality and type of incision were evaluated.FINDINGS: Four files from 26 files were excluded from study because of information deficits. Twenty two patients were included in the study. 77.3 of them (17 cases) were female. Recurrent laryngeal nerve palsy was seen in one patient. The most common symptom in 72.7% of patients (16 cases) was dyspnea. Pathology reports in 9 % of patients (2 cases) showed malignancy and in 91% (20 cases) were benign. All operations were done with cervical incision.CONCLUSION: According to the results of this study, the substernal goiter is often curable and the operation complications rarely happen.

There has been a recent interest at performing thyroid procedures robotically through an axillary approach. Although the technique for a unilateral thyroid lobectomy has been well established, there are controversies about whether a unilateral or bilateral axillary approach should be used for total thyroidectomy. Furthermore, there also questions as to whether a robotic total thyroidectomy would be oncologically equivalent to the traditional procedure. We have been performing our robotic total thyroidcetomies through a unilateral axillary approach, using principles learned in traditional surgery for removing substernal goiter. In this report, we describe a technique of robotic unilateral transaxillary total thyroidectomy validated by follow-up radioactive iodine uptake and serum thyroglobulin data.

A possibilidade de ser necessário um acesso combinado, com uma incisão cervical e outra torácica, torna o tratamento do bócio mergulhante um desafio tanto no pré quanto no intra-operatório. Discutimos uma padronização da técnica cirúrgica para minimizar a necessidade da abordagem torácica, tornando o bócio mergulhante uma patologia tratável cirurgicamente, por uma única incisão cervical, e com baixos índices de complicações. OBJETIVO: Avaliar a abordagem cirúrgica do bócio mergulhante por cervicotomia e analisar as complicações cirúrgicas. MATERIAL E MÉTODOS: Foi realizada uma coorte histórica com corte transversal por análise retrospectiva dos prontuários de pacientes submetidos à tireoidectomia no período de maio de 2002 a julho de 2007. Um total de 316 pacientes foi submetido à tireoidectomia sendo 33 (10,4%) por bócio mergulhante. RESULTADOS: Todos os 33 pacientes foram tratados cirurgicamente por via cervical sem necessidade de esternotomia. Não foram observadas lesões definitivas de nervo laríngeo inferior ou hipoparatireoidismo definitivo. Apenas 2 pacientes apresentaram paresia de nervo recorrente e 2 pacientes foram reabordados por hematoma cervical. CONCLUSÃO: Pacientes com bócio mergulhante podem ser tratados cirurgicamente por uma única incisão cervical com segurança e baixos índices de complicação.The possibility of needing a combined access, with neck and chest incisions makes the treatment of substernal goiter a challenge both in the pre-op and the intraoperative. We hereby, discuss a standardization of the surgical technique to minimize the need for a chest approach, making the substernal goiter a surgically treatable disease, through a single neck incision, and with low indices of complication. AIM: to assess the substernal goiter surgically approach through a neck incision and to analyze the surgical complications. MATERIALS AND METHODS: we carried out a historical cohort by retrospective analysis of the charts of patients submitted to thyroidectomy, and 33 of them (10.4%) had substernal goiter. RESULTS: all 33 patients were surgically treated through a neck incision without the need for sternotomy. We did not observe definitive lesions in the inferior laryngeal nerve or definitive hypoparathyroidism. Only 2 patients had recurrent nerve paresis; and 2 patients were re-operated because of a neck hematoma. CONCLUSION: patients with substernal goiter can be safely treated surgically through a single neck incision, bearing low complication rates.

Large substernal goiters have presented a challenge to surgeons since the beginning of thyroid surgery. With the widespread use of cross-sectional imaging and high-resolution ultrasound, more thyroid pathology is identified every year. In the setting of compressive symptoms, refractory hyperthyroidism, cosmetic concerns, malignancy, or even prophylaxis, thyroidectomy is indicated for large substernal goiters. Our aims are to present (1) the rationale and an algorithm for a concise preoperative assessment for thyroidectomy and (2) a detailed stepwise description of the procedure—emphasizing safety—for a large substernal goiter. This description is complemented by a medical artist's illustrations to emphasize the salient points of dissection. With sound surgical technique, thyroidectomy, although still sometimes quite challenging, may be performed safely, with rare need for median sternotomy, providing great relief to the patient.

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.

Objetivos: describimos en este trabajo las generalidades, epidemiología, características clínicas y los resultados de una serie de 50 pacientes operados en el Servicio de Cirugía Endocrina del Hospital Universitario Marqués de Valdecilla en un periodo de 4 años. Métodos: presentamos una serie quirúrgica de 50 pacientes aquejados de bocio intratorácico primario, operados en su totalidad a través de cervicotomía y en quienes se practicó tiroidectomía total. Resultados: 80% de los pacientes presentaban factores de riesgo quirúrgicos. La principal manifestación al diagnóstico fue la masa cervical (70%), seguida de disnea (60%), que se asoció a disfagia en un 30% de los pacientes y a disfonía en un 10%. Un 92% de los bocios operados fueron benignos, y la principal complicación postoperatoria fue la ronquera transitoria (8%). Conclusión: el bocio intratorácico aparece preferentemente en mujeres de mediana edad (84%). La cirugía es un procedimiento seguro, a realizar en aquellos pacientes con clínica de dificultad respiratoria, incluso en presencia de factores de riesgo quirúrgicos. Es infrecuente encontrar secuelas permanentes derivadas de la cirugía, tales como el hipoparatiroidismo (4%) y la parálisis recurrencial (2%). Objetivos: describimos en este trabajo las generalidades, epidemiología, características clínicas y los resultados de una serie de 50 pacientes operados en el Servicio de Cirugía Endocrina del Hospital Universitario Marqués de Valdecilla en un periodo de 4 años. Métodos: presentamos una serie quirúrgica de 50 pacientes aquejados de bocio intratorácico primario, operados en su totalidad a través de cervicotomía y en quienes se practicó tiroidectomía total. Resultados: 80% de los pacientes presentaban factores de riesgo quirúrgicos. La principal manifestación al diagnóstico fue la masa cervical (70%), seguida de disnea (60%), que se asoció a disfagia en un 30% de los pacientes y a disfonía en un 10%. Un 92% de los bocios operados fueron benignos, y la principal complicación postoperatoria fue la ronquera transitoria (8%). Conclusión: el bocio intratorácico aparece preferentemente en mujeres de mediana edad (84%). La cirugía es un procedimiento seguro, a realizar en aquellos pacientes con clínica de dificultad respiratoria, incluso en presencia de factores de riesgo quirúrgicos. Es infrecuente encontrar secuelas permanentes derivadas de la cirugía, tales como el hipoparatiroidismo (4%) y la parálisis recurrencial (2%). Grado en Medicina