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Airway obstruction due to substernal goiter is a tracherous complication of an uncommon entity. Five patients with substernal goiter are presented who manifested a complete clinical spectrum of airway obstruction varying from post ptussic inspiratory wheezing as the only indication of obstruction to sudden near-fatal respiratory arrest. In all patients, multiple X-ray views of the neck and upper thorax preoperatively showed either tracheal narrowing or displacement. Extreme anterior angulation of the trachea in one patient and bilateral compression in another required thyroidectomy to be carried out under local anesthesia. No correlation existed between weight of the gland found at surgery and intensity of obstructive symptoms, but tracheal compression in the thoracic inlet was a common finding. Following surgery, all patients were free of symptoms and signs of airway obstruction.

Two cases of atrial septal defect with the unusual complication of recurrent laryngeal nerve paralysis are presented. The necessity of exact diagnosis of congenital heart disease is stressed because both patients were erroneously suspected of having diseases which are amenable to surgical treatment, namely, patency of the ductus arteriousus in one instance, and substernal goiter in the other.

INTRODUCTION“Forgotten” goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy.PRESENTATION OF CASEWe report two cases with forgotten goiter. One underwent total thyroidectomy due to thyroid papillary cancer and TSH level was in normal range one month after surgery. The thyroid scintigraphy scan revealed mediastinal thyroid mass. The second case underwent total thyroidectomy due to Graves’ disease and TSH level was low after surgery. At postoperative seventh year, patients were admitted to our Endocrinology Division due to persistent hyperthyroidism and CT scan revealed forgotten thyroid at mediastinum. Both patients underwent median sternotomy and mass excision, there was no morbidity detected after second surgical procedures.DISCUSSIONIn the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter. Although in some cases, it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid with a thin fibrous band or vessels. Absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray do not excluded the substernal goiter.CONCLUSIONRetrosternal goiter should be suspected if the lower poles could not be palpated on physical examination and when postoperative TSH levels remained unchanged.

SUMMARY Goiter is a localized or generalized thyroid hypertrophy. It can remain within the cervical region or grow down until it invades the mediastinum. The signs and symptoms depend on the size and location of the goiter. Although drugs and radioactive iodine are often used to treat thyroid disease, the presence of symptomatic substernal goiter is a clear indication for surgery. Death or postoperative complications rarely occur. We present a case of a 71-year-old man with recurrent thyroid pathology in the form of substernal goiter and hyperthyroidism even after partial thyroidectomy. The importance of this relates to the clinical evolution, volume, and location of the goiter as well as the surgical and pharmacological approach. RESUMO O bócio é a hipertrofia da glândula tiroide localizada ou generalizada. Esta pode localizar-se na região cervical ou crescer através do mediastino. Os sinais e sintomas dependem do tamanho e da localização do bócio. Embora os fármacos e o iodo radioativo sejam frequentemente usados para tratar doenças tireoidianas, a presença do bócio subesternal sintomático é uma clara indicação para a cirurgia. A morte ou complicações pós-operatórias são raras. Apresentamos o caso de um homem de 71 anos com recorrência de patologia tireoidiana sob a forma de bócio subesternal e hipertireoidismo após tireoidectomia parcial. A importância desse caso relaciona-se com a evolução clínica, o volume e a localização do bócio e a abordagem cirúrgica e farmacológica desse tipo de patologia.

A substernal goiter may descend into the thorax. However, a truly aberrant intrathoracic thyroid represents a rare and anatomically different entity that requires appropriate modifications in approach and surgical technique.

1)"Nonallergic asthma" can occur from any condition in which there is a partial obstruction of the laryngotracheobronchial tree. It can also occur from sudden dilatation of the left ventricle. 2)We have discussed patients whose wheezing and dyspnea were due to (1) a leiomyoma of the trachea, (2) a carcinoma of the carina, (3) a substernal goiter, (4) silicosis of the lungs, (5) acute cardiac dyspnea (cardiac asthma), and (6) bronchiectasis. 3)We urge all allergists to become more proficient as internists, and also suggest that all internists learn enough about allergy so that they can make correct diagnoses and hurry the allergy surveys which are so important in the treatment of true allergic conditions.

Substernal goiter, also said cervico-mediastinic goiter, is a thyroid formation with cervical departure that goes beyond, with stretched neck, the superior thoracic strait for at least 3 cm and that preserves, generally, the parenchimal or fibrous connections between the cervical and thoracic portion, maintaining a direct vascularization supplied by the thyroid arteries. The prevalence of this pathology is very variable and fluctuates between 1.7% and 30% of all thyroid damages. The actual classification is provided by the radiologic examination of the chest and, above all, by the new techniques of imaging.In the period between January 1998 and December 2003, 332 patients with thyroid pathology have been treated surgically. Forthy-five (13.5%) of these were afflicted with a cervico-mediastinic goiter. In 32/45 (71.1%) cases a total thyroidectomy has been performed by collar carving in accordance with Kocher; in 11/45 (24.5%) cases an hemithyroidectomy has been performed by collar incision; in 2/45 (4.4%) cases, already submitted to surgical intervention of isthmus-lobectomy a totalization has been performed.The surgical technique foresees always an anterior collar neck incision. This way of access is to prefer in the substernal goiters, both for the presence of a cervical vascularization easy to control and for the possibility, nearly always realizable, to dislocate the goiter by that way. As for what concerns the results of the histological examination, in 2/45 (4.5%) cases it has been set a diagnosis of follicular carcinoma (one of them surely invading and the other, leastly invading), in 3/45 (6.6%) cases papillary carcinoma, in 4/45 (8.8%) cases colloido-cystic goiter, in 33/45 (73.5%) cases micro-macrofollicular hyperplasia (in one of which contemporarily compromise from lymphoma of Hodgkin); in 3/45 (6.6%) cases of adenomatous hyperplasia of the thyroid.The surgical approach has been in all cases the collar neck incision in accordance to Kocher, and it has never been necessary to associate a sternotomy or thoracotomy. After the intervention, in all the patients the symptomatology tied to the mediastinal compression has disappeared. The goiter showed signs of neoplastic degeneration in 11.1% of the cases, with prevalence of the papillary carcinoma in the 6.6% and, in the remaining 4.5%, of follicular carcinoma. These data are superimposable to the data gathered in other surveys. All the patients passed the post-operating hospitalization in optimal conditions and have been discharged during the fourth post-operating day with the prescription of increasing levothyroxine doses according to the body weigh.

A substernal goiter is a common mediastinal mass that can usually be recognized as contiguous with the body of the thyroid. We report the rare occurrence of a mediastinal goiter that demonstrated no connection with the cervical thyroid on either CT or at thoracotomy. Pathologic examination confirmed this to be an intrathoracic goiter.

Intrathoracic goiter is a rare cause of superior vena cava syndrome. We present the findings in a patient in whom the syndrome was precipitated by therapy with propylthiouracil and remitted on withdrawal of the medication. The superior vena cava syndrome did not recur on medical management, suggesting that surgery is not always indicated in this setting.

The unusual coexistence in a woman of 34 years of a cervical thyroid and a heterotopic mediastinal thyroid is recorded. Both thyroids had undergone non-toxic nodular enlargement. Recurrent enlargement was noted in the cervical gland 12 months after transpleural thoracic removal of the mediastinal goitre, whilst no corresponding change has so far been noted in the mediastinum. The literature on heterotopic thyroid is briefly reviewed and the diagnosis discussed.

To the Editor. —The article by Ladenson et al in the MayArchives(1983; 143:1015-1017) concerning a sequestered substernal goiter notes that the substernal component failed to concentrate iodine 123 or Tc 99m. Neither of these radionuclides are appropriate imaging agents for substernal thyroid tissue. The relatively low-energy γ-radiations of these isotopes (technetium Tc 99m, 140 keV; 123 I, 159 keV) are not able to penetrate the bone of the manubrium and sternum to any substantial degree. Substernal goiters should be imaged with iodine 131 whose 364-keV γ-radiations are much more likely to successfully image substernal functional thyroid tissue.

• 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. ( Arch Surg 1984;119:323-326)

In Reply. —Dr Rudavsky argues that neither 123 I nor technetium Tc 99m are appropriate radionuclides for the imaging of substernal thyroid tissue. Although the γ-emissions of these isotopes are, indeed, less energetic than those of 131 I, we do not agree that they are incapable of penetrating the bones of the anterior thorax. In fact, the calculated attenuation of γ-photons by 2cm of bone are 0.26 for 123 I and 0.18 for 131 I; ie, there would be almost as many photons penetrating bone from 123 I (74%) as 131 I (82%). In addition to these theoretical considerations, we are unaware of any report of substernal thyroid tissue successfully imaged with 131 I after failure of visualization with 123 I. We do concur that Tc 99m is not as useful an agent for the assessment of substernal thyroid tissue, but principally because of its high thoracic background activity. The

• A young woman with a normally located and only subtly nodular thyroid gland in the neck was found to have a clinically distinct and radioisotopically "cold" anterior mediastinal mass, which proved to be a benign colloid adenoma. While this constellation of findings usually suggests the presence of a nonthyroidal neoplasm, eg, lymphoma, thymoma, or teratoma, our case illustrates that sequestered benign nodular goiter should also be considered in the differential diagnosis. Clinical clues, such as a nodular thyroid gland, movement of the mass with deglutition, and a family history of nodular goiter, should suggest this possibility. A characteristic computed tomographic appearance may also prove useful in recognition of this rare disorder. ( Arch Intern Med 1983;143:1015-1017)

Although intrathoracic goiter is relatively frequent, its complication by suppuration is exceedingly rare. In a careful review of the literature, the only case found was one reported by Kalbfleisch1in 1920, in which the condition occurred in a young woman following a spontaneous abortion. Gas bacilli were present in the uterine secretions, although no local infection was observed. In the course of her illness, it was noted that a substernal goiter was present. In view of the septic course and local symptoms referable to the goiter, the diagnosis of either a complicating suppuration or a hemorrhage into the thyroid was considered. Operation was performed, and a suppurative intrathoracic goiter due to gas bacilli was found. Drainage was instituted, and recovery followed. Acute thyroiditis has often been observed. Clute and Lahey2described two types: (1) simple thyroiditis, which is more common, usually follows infection of the upper respiratory tract