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At least 19 recordsLinked to original sources
PubMed1998

Use of a Foley catheter in the removal of a substernal goiter.

Substernal goiters present a technical challenge to the surgeon. Most substernal goiters may be removed through a cervical incision; however, a median sternotomy may be required in 1% to 2% of patients. To avoid a median sternotomy, many techniques have been described in the literature to facilitate extraction. Special spoons and clamps have been described, and techniques, such as morcellation, the drawer technique, and piecemeal extraction, have been popularized. We describe a method whereby a Foley catheter is used to deliver a large substernal goiter through a cervical incision. It consists of steady traction on the inflated balloon of a Foley catheter placed beyond the substernal component of the goiter. This method has been used successfully and safely on 2 patients and may obviate the need for a sternotomy.

Catheterization↗
PubMedDate not supplied

Substernal goiter: a clinical review.

Thyroid disease is a very common problem, but indications for surgery are few. We have seen a large number of patients with multinodular goiter. The main indications for surgery in thyroid disease include fear of malignancy, tracheo-esophageal compression, and cosmetic reasons. Tracheo-esophageal compression is most commonly noted in patients with mediastinal goiters. Substernal goiter is defined as those situations in which at least 50% of the gland is in the mediastinal location. Although its incidence has decreased, it remains prevalent in almost every country in the world today. SSG is best diagnosed by a thorough history and physical examination, complemented by airway films, fiberoptic laryngoscopy, and computerized tomography. The most common presenting symptoms are those produced secondary to compression effects. SSG show a poor response to medical treatment. Moreover, given their propensity to cause acute airway symptoms, surgical treatment should be considered in most cases. Extirpation of the gland is best performed through a collar incision, with the addition of a median sternotomy in select few and difficult cases. Median sternotomy is necessary in only 1% to 2% of cases. Operative mortality is negligible, and the incidence of complication is minimized by following strict surgical principles.

Diagnostic Imaging↗
PubMed1990

A large substernal goiter as a cause of a pulmonary perfusion defect.

A pulmonary perfusion defect was caused by an extremely large anterior mediastinal mass subsequently proved by I-131 imaging to be an intrathoracic extension of a cervical goiter. Substernal goiter is not known to be reported previously as one of the causes of a perfusion defect in lung scanning.

Aged↗
PubMedDate not supplied

Surgical treatment of substernal goiter.

BACKGROUND: Substernal goiter differs from its cervical counterpart in regard to its clinical presentation, surgical management, pathological analysis and postoperative complication. METHODS: Retrospective analysis of 1320 thyroidectomies performed at the Hacettepe University Hospital between 1990 and 1997. RESULTS: 30 (2.3%) of 1320 thyroidectomies underwent operation for removal of substernal goiters in an 8-year period. The most common symptom was cervical mass (67%) and 33% of the patients were asymptomatic. Computerised tomography was the most accurate pre-operative test for detecting substernal extension. Substernal goiters were removed by collar incisions in 93% of the cases. The pathology was generally found to be benign (94%), but follicular carcinoma was present in two (6%) patients. There was no mortality and no complications were observed in 73% of the patients. CONCLUSIONS: The presence of substernal goiter is an indication for removal given the lack of any effective medical therapy, low surgical morbidity, risk of malignancy and acute obstructing symptoms.

Adult↗
PubMedDate not supplied

Substernal goiters.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. DISCUSSION: 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.

Adenocarcinoma, Follicular↗
PubMed1985

Substernal goiter.

The literature on substernal goiter from the seventeenth century to the present is reviewed. Substernal goiter may be defined as any thyroid enlargement that has its greater mass inferior to the thoracic inlet. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. Patients are generally in the fifth decade of life, and women predominate. Most patients experience dyspnea, stridor, or dysphagia, but 15 to 50% are asymptomatic; symptoms are often positional, and acute stridor may occur. Ten to twenty percent have no cervical mass or tracheal deviation on examination, and virtually all patients are euthyroid. Standard chest roentgenograms are often diagnostic, but computed tomographic or radioactive iodine scans may be helpful. The presence of a substernal goiter in all but the highest-risk patients is an indication for resection, usually through a cervical collar incision; an occasional patient will require sternotomy or thoracotomy. Death or major complications should be rare postoperatively. Substernal goiters are adenomatous and benign, but carcinoma occurs in 2 to 3% and may be occult. Patients should be followed closely, as these goiters may recur.

Adolescent↗
PubMed1995

Management of patients with substernal goiters.

The presence of a substernal goiter is an indication for thyroidectomy, even in asymptomatic patients, because there is no other effective method of preventing growth of the goiter. Both primary and secondary substernal goiters usually exhibit slow but steady growth, which leads to tracheal, esophageal, vascular, and neurologic compression syndromes. Airway obstruction, which poses a life-threatening situation, may be suddenly precipitated by spontaneous or traumatically induced bleeding into the substernal goiter, as well as by tracheal infections. Substernal goiters can also produce symptoms of thyrotoxicosis. In addition, substernal goiters are known to have a relatively high incidence of malignancy. CT scans permit proper distinction between primary and secondary goiters and allow for sound preoperative planning. Advances in anesthetic techniques and the use of small-caliber endotracheal tubes facilitate proper perioperative management, even for patients with significant respiratory compression symptoms. A tracheostomy is rarely necessary. Aggressive surgical therapy for substernal goiters avoids life-threatening situations and results in minimal morbidity and practically zero mortality when performed by a surgeon experienced in managing such patients. Resection of substernal goiters generally can be accomplished through a transcervical approach, either by digital mobilization alone or with the addition of a spoon technique. Morcellization or fragmentation of the goiter is less desirable because of the possibility of dissemination of potential malignancies within the goiter. Primary intrathoracic goiters, recurrent goiters, and malignant goiters often require a median sternotomy for safe removal. The recurrence rate of goiters after surgical removal is low.

Adenoma↗
PubMed1999

Bilateral recurrent nerve paralysis associated with multinodular substernal goiter: a case report.

Substernal goiter is an infrequent occurrence and is found in two to five per cent of all patients undergoing thyroid surgery. These lesions are well known to cause respiratory symptoms and alterations in phonation due to direct compression of airway structures. Infrequently, unilateral recurrent nerve palsy has been reported in patients with substernal goiter. We report a case of bilateral recurrent nerve palsy associated with multinodular substernal goiter in an 89-year-old female who presented in respiratory distress.

Aged↗
PubMed1993

A case report of substernal goiter.

A case of substernal goiter is reported. A 78-year-old female was admitted to our hospital with no symptoms. Chest roentgenography on admission showed that a mass of 3 by 5 cm in size with calcification located in the substernal region. Computed tomography of the chest and aortography revealed that the mass was attached to the trachea, but the connection to the great vessels was not clear. Pathological findings of the incisional biopsy specimen showed thyroid tissue with no evidence of malignancy. Our clinical diagnosis was substernal goiter. Surgery was not carried out in this case, based on the literature. Surgery is indicated in case of malignancy or in cases with severe illness such as respiratory disorder and superior vena cava syndrome.

Aged↗
PubMed1995

Substernal goiter.

The management of a substernal goiter is a problem which has challenged surgeons since its first description in 1749. While the overall incidence in the United States has decreased with the routine use of iodized salt, the development of large multinodular substernal goiters in the rest of the world is still common. In addition, even in those regions where they are less common, knowledge of their treatment is important as they can represent up to 7% of mediastinal tumors. Certainly, the majority are large, benign masses found in the superior and anterior mediastinum, although from 3 to 15% can be malignant in nature. The presenting symptoms generally relate to the compressive nature of the mass on nearby structures. Up to 90% of patients report some form of respiratory symptoms in association with these masses. Diagnostic evaluation should include chest x-ray and computed tomographic (CT) scan. Needle aspiration biopsy should be avoided due to its dangerous substernal location. The treatment is surgical, as medical therapy is generally unsuccessful. Perioperative management should include careful evaluation of the airway as the extent of compression and deviation caused by the mass can lead to a difficult intubation. The vast majority of substernal goiters can be removed via a cervical incision; occasionally sternotomy or thoracotomy is necessary. Although rare, tracheomalacia secondary to prolonged compression of the trachea by the mass needs to be watched for postoperatively. Overall, the results of surgical treatment are excellent, as morbidity and mortality are minimal and patients can expect full relief of symptoms secondary to these mediastinal masses.

Female↗
PubMed1994

Surgical management of substernal goiter.

Seventeen cases of large substernal goiter are reviewed. The commonest clinical features were frequent upper respiratory tract infections, dyspnea and a cervical mass. Five of the patients had previous thyroidectomy. The substernal goiter was located in the right chest in 11 cases, the left chest in five and bilaterally in one case. On computed tomograms it was pretracheal or prevascular in ten cases and retrovascular in seven. Tracheal deviation was present in 15 cases, causing tracheal compression or stenosis in 14. Thyroidectomy was performed on all 17 patients (8 subtotal, 9 total) through a low transverse collar incision. The recommended technique for substernal goiter extending from the neck to a level below the subcarinal region includes concomitant finger dissection and upward traction of the cervical thyroid through the subcapsular plane, with obliteration of the postresection substernal dead space by sutures. Follow-up radiography showed that all the deviated tracheas had resumed near normal position 2-3 months postoperatively and the average diameter of the compressed tracheas had increased significantly.

Adult↗
PubMed2004

Predictors of airway complications after thyroidectomy for substernal goiter.

HYPOTHESIS: Airway complications after thyroidectomy for substernal goiter can be predicted by preoperative symptom profiles, radiologic findings, or other factors. DESIGN: Retrospective review. Settings A university tertiary care center and a veterans' hospital. PATIENTS: Sixty patients with substernal goiter who underwent thyroidectomy between 1993 and 2002. MAIN OUTCOME MEASURES: Symptoms, preoperative radiologic findings, extent of thyroid resection, tumor size, and postoperative complications. RESULTS: Dysphagia was the most common preoperative symptom (n = 26), followed by dyspnea (n = 21), orthopnea (n = 13), and hoarseness (n = 6); 18 patients (30%) had superior vena caval obstruction. Thirteen patients (22%) were asymptomatic. Preoperative imaging identified tracheal deviation or compression in 45 patients (75%). Substernal goiter was resected via a cervical approach in 59 patients (98%). Of 47 patients with preoperative symptoms, 41 (87%) reported improvement postoperatively. Seven patients (12%) had postoperative airway complications: 1 developed a neck hematoma requiring reoperation, and 6 could not be immediately extubated; all 6 were successfully extubated after 1 to 10 days. Patients with airway complications were older (mean +/- SEM, 70.3 +/- 3.6 years vs 61.5 +/- 2.2 years), had larger goiters (mean +/- SEM, 210.7 +/- 37.0 g vs 112.2 +/- 7.7 g), and were more likely to have tracheal compression on preoperative imaging than those who did not have complications (P<.05). CONCLUSIONS: Most patients with substernal goiters underwent thyroid resection via a cervical approach with an improvement in symptoms. The few patients who developed postoperative airway complications were older, had larger goiters, and were more likely to have tracheal compression on preoperative imaging than those without airway complications.

Age Factors↗
PubMedDate not supplied

Operative management of substernal goiter: analysis of 52 patients.

Thyroid surgery for substernal goiter is an uncommon operation. This study was carried out to evaluate the clinical presentation, workup, surgical complications, and risk of malignancy for substernal goiter. From January 1995 to June 2001, 52 patients [27 men and 25 women (ratio, 1.1:1); average age of 52 years (range, 26-71 years)] underwent thyroid surgery for substernal goiter at Akdeniz University Hospital. All patients were symptomatic at presentation. A chest radiograph was used for most patients with a computed tomography scan being by far the most helpful in the study. A cervical approach was adequate for resection of the lesions in 50 (96%) patients. Two (4%) patients required medial sternotomy for removal of thyroid tissue. There was no perioperative mortality. Transient recurrent laryngeal nerve (RLN) palsy occurred in 2 (4%) patients, and permanent RLN occurred in 2 (4%) patients. The incidence of transient and permanent hypoparathyroidism was 8% and 6%, respectively. Other complications included wound infection in 2 (4%) patients and postoperative bleeding in 1 patient (2%). Histopathologically, 46 (88%) lesions were benign and 6 (12%) were malignant. Because the history of substernal goiter is progressive enlargement, surgical removal of thyroid tissue is always indicated and should be performed as soon as possible, unless there are contraindications for surgery. Cervical collar incision is nearly always adequate, with few exceptions.

Adult↗
PubMed2005

Substernal goiter: an unusual cause of respiratory failure after coronary artery bypass grafting.

Substernal goiter can cause extrathoracic upper airway obstruction. Since cardiopulmonary bypass results in a systemic inflammatory response syndrome characterized by an increase in capillary permeability and edematous changes in many tissues including the thyroid gland, an existing nonobstructive substernal goiter may become obstructive postoperatively. We describe the case of a patient with an asymptomatic substernal goiter who required urgent thyroidectomy for tracheal obstruction after elective coronary artery bypass grafting. To the best of our knowledge, ours is the 1st such case reported in the English-language medical literature. This case illustrates that, in cases of acute postoperative respiratory failure after open heart surgery, tracheal obstruction caused by enlarged substernal goiter should be considered in the differential diagnosis.

Acute Disease↗
PubMed1975

Substernal goiter with superior vena caval obstruction.

Substernal goiter with vena caval obstruction remains an interesting diagnostic and therapeutic problem. Since 85 to 90 percent of superior vena caval obstructions are due to a malignant disease, an intrathoracic goiter represents one of the benign, curable causes of this syndrome. This report describes the clinical course of a 44-year-old woman who presented with this entity and was successfully corrected by surgical intervention. A discussion of diagnostic, operative, and prognostic considerations is presented.

Constriction↗
PubMed2000

Surgical management of substernal goiter.

PURPOSE: We describe the clinical results and complications associated with different surgical approaches to the treatment of substernal goiter. METHODS: We retrospectively reviewed the medical records of 56 patients treated for substernal goiter from 1983 through 1999. Eight had undergone previous thyroidectomy. Posterior mediastinal goiter was diagnosed in eight patients, hyperthyroidism in seven, acute respiratory failure in three, and superior vena cava syndrome in two. All but one of the patients underwent thyroidectomy. RESULTS: Thyroid scan revealed that 88% of patients had substernal goiter. A cervical incision alone was used in 46 of 55 patients. Nine patients underwent thyroidectomy via a thoracic approach. Both lobes were resected in 16 patients. Two deaths occurred: one patient suffered a stroke and another patient developed pneumonia after surgery. The most frequent complication was recurrent laryngeal nerve injury, followed by removal of a normal parathyroid gland and pneumonia. Multinodular goiter occurred in 52 patients. Resected goiter with occult malignancy was found in three patients, two of whom underwent lobectomy only. These three patients had survived at 5, 7, and 11 years postoperatively, respectively. All patients with tracheal lumen narrowing showed a normal sized tracheal lumen 2 to 3 months postoperatively. CONCLUSION: Our data indicate that the presence of a substernal goiter should be considered an indication for resection based on risk of acute respiratory distress, risk of malignancy, and lower surgical morbidity. Most secondary substernal goiters can be simply resected through cervical incision and curation.

Adult↗
PubMedDate not supplied

[Substernal goiter: personal experience].

AIM OF THE STUDY: The Authors report on their experience in the surgical treatment of substernal goiter. MATERIAL AND METHODS: Between 1972 and 2004, 222 patients with substernal goiters were observed among 2720 patients undergoing surgical treatment for various thyroid diseases (8.16%). Seventy patients underwent subtotal thyroidectomy and 152 total thyroidectomy. A cervical approach was employed in 213 cases, a sternotomy was required in 7 patients while a thoracotomy was necessary in 2 cases. Postoperative complications were definitive hypoparathyroidism in 9 cases (4%), recurrent laryngeal nerve palsy in 5 patients (2.2%) and postoperative bleeding in 4 cases (1.8%); there was no intraoperative mortality. CONCLUSIONS: In substernal goiter it is necessary to define its exact relationship to neck and mediastinal structures in order to establish the most appropriate surgical approach. In the majority of the cases total thyroidectomy is possible through a cervical approach with an acceptable morbidity rate. When dissection of the substernal goiter is difficult and recurrent laryngeal nerve is not clearly identified, partial sternotomy is required to enable a better control of the nerve and the vessels with only a minimal morbidity rate. Thoracotomy is rarely necessary.

Adult↗