Bocio endotorácico / Endothoracic Goiter

Introducción: Un bocio se considera intratorácico cuando más de un 50 por ciento de la glándula tiroides está en el mediastino, o sea, por debajo del nivel del estrecho torácico superior. Se trata de una enfermedad poco frecuente que padece aproximadamente el 3 por ciento de los pobladores del mundo. La incidencia del bocio nodular ha disminuido debido a la ingestión en algunos países de sal yodada y alimentos ricos en yodo. Esta enfermedad alcanza alrededor del 10 por ciento de las masas mediastínicas. Objetivo: Presentar el caso de un paciente masculino, operado de bocio endotorácico en la provincia de Cienfuegos. Presentación de caso: Se presenta un paciente masculino, de 48 años de edad, que acude a consulta y refiere aumento de volumen del cuello en la región anterior, que se acompaña de decaimiento y en ocasiones disfagia tanto a los alimentos líquidos como a los sólidos. Además, refiere ligera disnea que tolera adecuadamente cuando realiza las actividades de la vida diaria. Por tratarse de una enfermedad poco frecuente, se considera de interés científico publicar el caso para conocimiento de los profesionales dedicados al estudio y tratamiento de las afecciones tiroideas. Conclusiones: El bocio endotorácico es una entidad poco frecuente y en todos los casos requiere de intervención quirúrgica(AU)

Introduction: A goiter is considered intrathoracic when more than 50 percent of the thyroid gland is in the mediastinum; in other words, below the level of the superior thoracic outlet. It is a rare disease that affects approximately 3 percent of the world's population. The incidence of nodular goiter has decreased due to the ingestion of iodized salt and iodine-rich foods in some countries. This disease accounts for about 10 percent of mediastinal masses. Objective: To present the case of a male patient operated on for endothoracic goiter in the province of Cienfuegos. Case presentation: The case is presented of a 48-year-old male patient who comes for consultation referring a volume increase in the anterior neck region, accompanied by decay and sometimes dysphagia to both liquid and solid food. In addition, he reports slight dyspnea that he tolerates adequately when performing daily living activities. Since this is a rare disease, it is considered of scientific interest to publish the case for the knowledge of professionals dedicated to studying and treating thyroid disorders. Conclusions: Endothoracic goiter is a rare entity and, in all cases, requires surgical intervention(AU)

Bocio endotorácico en un adulto / Endothoracic goiter in an adult

Se presenta el caso clínico de un paciente de 48 años de edad, quien acudió a la consulta de Patología de Tiroides del Hospital Provincial Dr. Gustavo Aldereguía Lima de Cienfuegos, por presentar aumento de volumen del cuello en la región anterior, decaimiento, ocasionalmente disfagia y ligera disnea. Al examen físico se constató un tumor en la región anteroinferior y lateral derecha del cuello, movible, que se prolongaba hacia abajo a la parte superior del tórax. Se realizó hemitiroidectomía derecha con exéresis de la prolongación endotorácica. El paciente evolucionó favorablemente.

The case report of a 48 years patient is presented. He went to the Thyroid Pathology Service of Dr. Gustavo Aldereguía Lima Provincial Hospital from Cienfuegos, due to an increase of volume in the anterior region of the neck, weakness, occasionally deglutition disorders and light dyspnea. A tumor was verified in the anteroinferior and lateral right region of the neck, movable, that was prolonged downward to the superior part of the thorax when the physical exam was carried out. A right hemithyroidectomy was carried out with exeresis of the endothoracic extension. The patient had a favorable clinical course.

Goitre plongeant Particularités cliniques et thérapeutiques / Sub-sternal goitre: Clinical and therapeutic features

Etudier les caractéristiques cliniques, radiologiques et thérapeutiques des goitres plongeants et établir un arbre décisionnel de prise en charge Méthodes: Nous rapportons une étude rétrospective portant sur 67 cas de goitre plongeant colligés sur une période de 27 ans entre 1990 et 2016. Résultats: L'âge moyen des patients était de 53 ± 15,1 ans et le sex-ratio de 0,24. La tuméfaction basicervicale antérieure était le motif de consultation le plus fréquent, rapportée dans 82% des cas associée à des signes de compression dans 31% des cas. Une paralysie récurrentielle unilatérale a été objectivée dans quatre cas. Une radiographie de thorax a montré une opacité médiastinale dans 75% des cas et une déviation trachéale dans 85% des cas. Un scanner cervico-thoracique pratiquée dans 73% des cas a confirmé le diagnostic en objectivant cinq prolongements dépassant la crosse de l'aorte. Le traitement chirurgical était mené par voie cervicale dans 99% des patients et une sternotomie a été réalisée devant l'échec d'extraction par cervicotomie. Une paralysie récurrentielle postopératoire a été observée dans un cas et l'hypoparathyroïdie définitive a été rapportée chez six malades avec un recul moyen de trois ans. Conclusion: Les goitres plongeants sont devenus rares en Tunisie du fait de la prise en charge plus précoce des nodules thyroïdiens. Le scanner cervico-thoracique représente le gold standard pour l'étude et la confirmation du diagnostic du goitre plongeant ainsi que pour l'attitude thérapeutique. L'indication chirurgicale est toujours impérative devant le risque vital qu'il pose.

Substernal goiter and laryngopharyngeal reflux

ABSTRACT 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.

Combined Cervical and Video-Assisted Thoracoscopic Approch for Huge Substernal Goiter

Substernal goiter is defined as a thyroid mass of which more than half is located below the thoratic inlet. Substernal goiters must be removed surgically due to relation to compressive symptoms, potential airway compromise, and the possibility of an association with malignancy. Thyroidectomy for substernal goiter is usually carried out through a standard cervical approach. However, a few patients with various factors require an extracervical approach, usually by sternotomy. Recently, we successfully removed a substernal goiter that extended to the lower level of the aorta and tracheal carina though the combined cervical and video-assisted thoracoscopic approach. We present this case with a review of the literature.

Bocio intratorácico / Intra-thoracic goiter

Introducción: el bocio constituye la afección de la glándula tiroides que más es tratado en los servicios quirúrgicos, sin embargo, su posición anómala no es frecuente. Presentación de caso: paciente de 51 años de edad, con antecedentes de asma bronquial. Hace 3 años presentó un aumento de volumen de la región lateral izquierda del cuello y presencia de decaimiento, palpitaciones y disfagia ocasional, para lo cual llevó el tratamiento con levotiropsina sódica. Se indicaron estudios de la función tiroidea, radiografías de tórax (vista anteroposterior), ecografía de la tiroides y biopsia por aspiración con aguja fina. A través de la vía cervical se le realizó la tiroidectomía total corroborando que más del 50% de la glándula estaba en posición intratorácica, nódulos en ambos lóbulos y sin complicaciones; resultó ser un bocio coloide multinodular. Conclusiones: el bocio intratorácico responde poco al tratamiento médico, de preferencia se utiliza la tiroidectomía total por vía cervical ante síntomas de compresión siempre que sea posible.

Introduction: goiter constitutes the most treated condition of thyroid gland in surgical services, even though its anomalous position is not frequent. Case report: a 51 year-old patient with history of bronchial asthma. Three years ago the patient presented growth of volume of the lateral-left region of neck and presence of weakness, palpitations and occasional dysphagia, being treated with levothyroxine sodium. Studies of thyroidal function, thoracic radiographies (anteroposterior view), thyroid echography and fine needle aspiration biopsy were performed. Through the cervical line, total thyroidectomy was performed, confirming that more than 50% of the gland was in intra-thoracic position, there were nodules in both lobules without complications; it was a multinodular colloid goiter. Conclusions: intra-thoracic goiter has not a good response to medical treatment; when symptoms of compression are present, total thyroidectomy by cervical line is preferred whenever possible.

Insuficiência respiratória aguda secundária a bócio mergulhante da tireoide / Acute respiratory insufficiencysecondary to substernal thyroid goiter

Relato de caso de bócio mergulhante (BM) em idosa com longa história de bócio nodular tóxico (BNT) e que evoluiu com insuficiência respiratória aguda enquanto aguardava cirurgia eletiva para extirpação do bócio. A evolução das complicações respiratórias dessa paciente sugere que o tratamento cirúrgico do BM em idosos deveria ser feito o mais breve possível, após o surgimento de sintomatologia respiratória, para evitar complicações.

Case report of substernal thyroid goiter in an elderly woman with long record of toxic nodular goiter that progressed to acute respiratory insufficiency while waiting for elective surgery for extirpation of goiter. The development of respiratory complications suggests that the surgical treatment of substernal thyroid goiter affecting elderly people should be pursuit as soon as possible after the appearance of respiratory symptomatology as a means of avoiding complications.

Avaliação crítica de 33 pacientes com bócio mergulhante tratados cirurgicamente por cervicotomia / A critical analysis of 33 patients with substernal goiter surgically treated by neck incision

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 cento) 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 percent) 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.

A Case of Huge Substernal Goiter Causing Acute Respiratory Failure / 대한이비인후과학회지

Substernal goiter is defined as a thyroid mass of which more than half is located below the thoracic inlet. As substernal goiter enlarges within the bony thoracic cavity, and vascular and visceral structures may slowly become compressed and compromised. Airway obstruction can occur due to the compression or the displacement of the trachea. Tracheal compression may rarely lead to severe respiratory compromise. Recently, we experienced a case of huge substernal goiter causing acute respiratory failure in a 63-year old female. We present this case with a review of the literature.

Transcervical Approach for Mediastinal Mass Originated from Thyroid Gland: An Alternative Surgical Option Using Ballooning Catheter

PURPOSE: The aims of this study were to introduce an alternative surgical technique using a ballooning catheter and assess the outcomes of its use in patients with an upper mediastinal mass originated from the thyroid gland. METHODS: Between May 2001 and April 2004, 8 patients undewent an operation via a cervical approach using a ballooning catheter were enrolled in this study. The study group was reviewed by their clinical characteristics, diagnostic methods, postoperative results, histopathological findings and prognosis. Instead of a sternotomy, a ballooning catheter technique was used to assist in the transcervical delivery and extraction of these huge or deep mediastinal masses. The ballooning catheter was placed at the base of the mediastinal mass via a narrow plane which could not be reached by the surgeon's fingers. When the mediastinal mass was freed up by careful dissection with traction using an inflated ballooning catheter, could the mass was able to be delivered without injury to the surrounding tissues. RESULTS: There were 3, 2 and 3 cases of substernal goiters, substernal goiters combined with a papillary microcarcinoma and metastatic papillary carcinoma from thyroid cancer, respectively. The mean operation time and period of hospitalization were 121 minutes, (ranging from 70 to 195 minutes), and 6 days, (ranging from 3 to 10 days), respectively. In the 5 cases with a substernal goiter, the average size of the resected specimen was 9.9 cm, (ranging from 5.5 to 17.6 cm), with an average weight of 100.2 g, (ranging from 45 to 172.2 g). In the 3 cases of metastatic mediastinal lymph nodes, the postoperative 131I scan and serum thyroglobulin level showed no evidence of remnant metastatic tissue or cancer spillage. The median follow up duration was 24.8 months (ranging from 13 to 42 months). No major complications were documented, and no evidence of recurrence was encountered. CONCLUSION: The use of the ballooning catheter was found to be helpful in the transcervical removal of an upper mediastinal mass, and useful for substernal goiters. Furthermore, for mediastinal lymph node metastasis, this technique can be adopted as an alternative method in carefully selected cases.

Surgical Management of Substernal Goiter / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Substernal goiter, defined as any thyroid enlargement that has greater mass inferior to the thoracic inlet, is a relatively rare disease with a potential for malignancy and the risk of postoperative airway obstruction secondary to tracheomalacia. We investigated clinical characteristics of substernal goiters and analyzed the results of the treatment to establish modalities of the surgical management. MATERIALS AND METHODS: We examined, retrospectively, ten cases of substernal goiters and reviewed their clinical features, radiological findings, histopathologic findings, operative findings and postoperative complications. RESULTS: We found tracheal deviations in six patients, tracheomalacia in three patients and calcification in two patients. We performed partial thyroidectomy for 9 cases and total thyroidectomy and superior mediastinal dissection were done for a case which revealed to be follicular carcinoma. The main histopathologic findings were multinodular goiter in five cases, followed by follicular adenoma, and follicular carcinoma in one case. Endotracheal intubation was removed after 24 hours postoperatively for six cases who showed severe tracheal compression and tracheal deviation and the tracheopexy (tracheal suspension) to the sternum was performed for one case among them. CONCLUSION: Because of the possibilities of malignancy and the acute airway obstruction, the surgical treatment and careful postoperative airway management should be emphasized for substernal goiter.

Surgical Treatment of Substernal Goiters

Substernal extension of a goiter into the thoracic inlet endows a generally benign neck mass with morbid potential. The reported incidence varies between 1% and 15% of all thyroidectomies performed. Whether all patients with a substernal goiter should undergo an operation or whether the operation should be performed selectively remains controversial. From May 1989 to March 1996, 10 patients underwent thyroidectomies for substernal goiters, and those cases of resected substernal goiters have been reviewed to access the symptoms and signs that brought patients to surgery: the size and the position of goiter, the preoperative work-up, the risk associated with the operation, and the histopathologic state of the goiter. There were 3 male and 7 female patients, and their ages ranged from 40 to 68 years. The chief complaints were cervical mass (4), dyspnea (2), facial edema (1) and chest pain (1). No symtomatic cases (2) were also found. The average mass size was 8.4 cm (5-14 cm) and the average weight was 109 gm (41-350 gm). Although chest film was the most used, computed tomography was by far the most useful study. Thyroid scans often failed to show the substernal goiter. Fine-needle aspiration was not helpful because of inaccessibility. In the majority of the patients (7 cases), the substernal goiters were removed by a cervical incision. Three cases of goiters located deep to the carina level required a combined cervical and sternotomy approach or thoracotomy. In the cervical incision group, the complications were transient hypocalcemia (1) and unilateral recurrent laryngeal nerve injury (1). In the combined cervical and sternotomy approach or thoracotomy, unilateral recurrent laryngeal nerve injury (1) and bilateral recurrent laryngeal nerve injury (1) and mediastinitis (1) were the complications. An occult papillary carcinoma, which was not identified preoperatively, was found in one case. Removal was almost always accomplished via cervical incision and with low morbidity and no deaths. Also, the substernal goiters revealed unusual symptoms and signs, such as dyspnea, facial edema and chest pain, compared to usual thyoid goiters and were relatively bigger in size. In conclusion, most substernal goiter above the carinal level could be removed by cervical incision with a low rate of complication. The threat of compression, the substantial chance of malignancy, and the safety of resection mean that the presence of a substernal goiter is an indication for surgery.

Diagnosis and surgical treatment of the substernal goitre / 重庆医科大学学报

Objective:To investigate the clinical characteristics,diagnosis and surgical treatment of the substernal goitre.Methods:28 cases of substernal goiter operated were retrospectively analyzed.All were histopathologically proven.Results:This group included 25 secondary cases of cervical goitre and 3 primary cases.The clinical manifestations were cervical mass(25/28),thoracic discomfort(23/28) and dyspnoea(8/28).The preoperative diagnoses were established mainly on the basis of chest X ray combining with ~(131)Ⅰ scan.There was no operative mortality postoperatively, but 1 patient(3.6%)complicated with transient dysphonia and 3 cases relapsed.Conclusion:Chest X ray and ~(131)Ⅰ scan are helpful for making a diagnosis of substernal goiter before operation.Surgical removal of the tumor is the best choice with satisfactory prognosis.