Substernal goiter occurs when the thyroid gland or masses within the gland extend into the upper chest. Outcomes of transcervical surgical management of massive. Of the 127 patients who had a substernal goiter, 7 ultimately required a sternotomy. Surgical treatment of large substernal thyroid goiter. An extended toboggan technique for resection of substernal. The wide variation is undoubtedly influenced by regional endemic goiter belts and referral patterns, as most series have been collected at tertiary care institutions. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. Most show continuity with the cervical portion of the gland, although some have only a fibrous band connecting the substernal and cervical thyroid tissues. An extended toboggan technique for resection of substernal thyroid goiters. Substernal goiter definition of substernal goiter by the. Pdf a thyroid mass, most often a non toxic colloid goiter or occasionally an adenoma.
The reported incidence of substernal goiter ranges from 2. A thyroid mass, most often a non toxic colloid goiter or occasionally an adenoma, is not an unusual finding below the level of the thoracic inlet. Thyroid volume measured by ultrasonography is slightly greater in men than women, increases with age and body weight, and decreases. This chest xray shows a substernal thyroid which is compressing and displacing the trachea to the patients left the trachea outlined in light yellow should run straight from the mouthnose down to the lungs rather than being curved like it is in this. Treatment and prognosis most anterior substernal thyroid goitres are accessed via a transcervical approach. Some theories postulate that small cervical thyroid nodules descend beneath the pretracheal fascia, possibly aided by the negative intrathoracic pressures that. Substernal goiters are largely considered to result from the descent of a cervical goiter with the primary blood supply remaining in the neck, primarily from the inferior thyroid artery. Oct 01, 2019 when the presence and degree to which a goiter has substernal extension is unknown, ct scanning or mri of the neck and chest can help assess both the need for surgery and preoperative planning. These two studies look at how substernal goiters impact surgical outcome and how to predict who may need a procedure that requires opening the chest. Thyroidectomy definition thyroidectomy is a surgical procedure in which all or part of the thyroid gland is removed. This is what makes substernal thyroids a special case which deserve special attention. Enlarged thyroid glands ie, goiters often extend in the mediastinum posterior to the sternum, making the gland, by definition, a substernal or retrosternal goiter. At the other end of the spectrum, the majority of thyroid nodules are too small to see or feel at all, and are called nonpalpable nodules.
Large substernal thyroid goiter associated with saddle pulmonary embolism article pdf available in world journal of endocrine surgery 83. Long term follow up patient needed for future study. Great thyroid goiter with large heterogeneous nodules extending to middle mediastinum, associated with mediastinal lymphadenopathy,a histological study to assess malignancy is suggested. Jun 11, 2019 the most commonly accepted definition would include all goiters with a lower pole lying below the thoracic outlet. The normal thyroid gland resides in the neck, with both lobes wrapping gently around the trachea breathing tube. There were three minor complications and no deaths. Operative techniques in otolaryngology head and neck surgery. I had a substernal goiter removed in 08 the had did fna on thyroid before surgery said no cancer waited about 9 mths to have surgery but was having symptoms, surgeon did not want an emergency, so i had it done they got the goiter out and had to remove left side of thyroid to get it out well goiter wasnt cancer but the found cancer in the. Original article surgical treatment of large substernal. However, all goiters should be monitored by examination and biopsy for possible malignant.
Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. Many are asymptomatic and incidentally detected on ct as an anterior upper mediastinal mass. Increased level of thyroid stimulating hormone tsh, iodine deficiency in the diet and clinical reflection of many pathologies may cause this. May 23, 2001 an innability to discover the base of the thyroid gland is suggestive of a substernal goiter. Substernal goiters are usually extensions of the thyroid into the mediastinum. 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. It has usually appeared because one of the lower poles of the gland, which is rather given to enlarging, has, instead of growing forward to give a conventional goiter, grown backwards and down the neck into the top of the chest. When this occurs, thyroidectomy surgery excision of part or all of the thyroid gland has unique considerations that are important to understand for the surgeon and patient. Factors influencing extent of surgery for substernal thyroid. Some of these substernal goiters will remain small, and due to their location, they may not be noticed unless they become symptomatic. Substernal goiter surface anatomy, imaging and surgical.
American thyroid association statement on optimal surgical. The prognosis depends on a good preoperative preparation and rigorous postoperative followup. Simple endemic goiter is usually caused by lack of iodine in. Purpose all or part of the thyroid gland may be removed to correct a variety of abnormalities of the gland. Analysis of a single surgeon experience with 1 substernal goiters operated upon during a 10. There is general agreement that medical treatment is ineffective for substernal goiters. Goiter may be associated with a number of conditionsdiffuse toxic goiter, thyroiditis, thyroid tumor, and sporadic and endemic goiter. Feb 11, 2014 ct scan imaging for suspected substernal goiter can quantify the caudal extent, show the 3d shape, define any tracheal compression, and pinpoint the mediastinal compartments that are occupied by goiter anteriorposterior.
Does radioiodine therapy have an equal effect on substernal. The patient was a 57yearold female, who visited our hospital for surgical treatment for a large substernal goiter. Elevated tsh is also thought to contribute to an enlarged thyroid in the goitrous form of. Postoperative histopathological examination showed 10 benign nodular goiter and 2 cases of thyroid adenoma. If there is evidence of pressure against the throat, or the possibility of a malignancy, the goiter may be removed surgically. It is more prevalent in adult women over 60 years of age, due to a progressive increase of the gland that invades the thoracic cavity. See clinical presentation and evaluation of goiter in adults, section on goiter with obstructive symptoms or suspected substernal goiter. It has been found that 80% of the substernal thyroid masses are of small extension type, 15% are of the partial type and 24% is of the. Usually, they will grow within the neck as shown in the picture of the woman on our goiter page. The vast majority of substernal goiters 8590% are located in the anterior mediastinum, with the remainder 1015% located in the posterior mediastinum 2, 12. Free thyroxine and triiodothyronine levels can be obtained. Noncontrast neck ct scans are usually sufficient unless a goiter is found to extend caudally past. Sterile tracheotomy kit was prepared for bedside tracheotomy was prepared. Contrastenhanced ct of the chest shows a large, contrastenhancing.
These include a thyroid gland extending 3 cm below the sternal notch or extension of the gland below the fourth thoracic vertebra. It was nearly 200 more years before the function of the thyroid was. Substernal goiter definition of substernal goiter by. It is difficult to define in a patient with a huge goiter in the neck as well as a considerable substernal component, as is often the case with a multinodular goiter. All or part of the thyroid gland may be removed to correct a variety of abnormalities of the gland. Substernal goiters develop for many of the same reasons that a normal goiter develops. Goiter, or benign enlargement of the thyroid gland, can be asymptomatic or can cause.
Thyroid lobectomy with excision of substernal goiter. In some cases, the chest needs to be surgically opened to remove these goiters, which is a more extensive and invasive operation. If the tsh is abnormal, a free t4 and free t3 should also be checked. The management of a substernal goiter is a problem which has challenged surgeons since its first description in 1749. Substernal goiter sg was first described by haller in 1749 and first surgically removed by klein in 1820. Our hospital settings, although not large, is a good representation of potential outcomes in a nonuniversity hospital. The simultaneous occurrence of cervical and ectopic retrosternal goitre should always be ruled out with a ct scan. Plz check the documentation of report and pick the appropriate codes from the above. Mar 28, 2012 imaging showed tracheal compression in 97. Substernal goiter is a rare disease of the thyroid gland.
Some multinodular goiters can become enormous, bulging out of the neck and over the collar bones or extending down into the chest behind the breastbone, a condition called substernal goiter. If the patient has a goiter an enlargement of the thyroid gland, causing a swelling in the front of the neck, it may cause difficulties with swallowing or breathing. Substernal goiter, also said cervicomediastinic goiter, is a thyroid formation with cervical departure that goes beyond, with stretched neck, the superior thoracic strait for at least 3 cm and. Ct scans obtained with the patients arms by the side are more accurate for determining substernal extent of goiter than when the arms are. Most substernal goiters can be managed through the transcervical approach, but a sternotomy is required in some cases. When thyroids get enlarged called a goiter, they can grow a number of different directions.
The radiologist needs to be aware of a potential pitfall that can influence the imaging appearance of thyroid goiter. The term goiter simply refers to the abnormal enlargement of the thyroid gland. During a 22year period, we treated 44 patients with intrathoracic multinodular goiter. This includes iodine deficiency, thyroid nodule mutations, exposure to radiation or they can be hereditary. Patients are generally in the fifth decade of life, and women predominate. Thyroid function tests tfts, including thyroidstimulating hormone tsh, free triiodothyronine ft3 and free thyroxine ft4 levels, were found to be. Substernal or mediastinal goiters develop from the thyroid gland and progressively migrate into the thoracic cavity because of their weight, negative thoracic pressure, respiratory movements, and. Surgical treatment of large substernal thyroid goiter 489 int j clin exp med 20.
In healthy adults without iodine deficiency, a normal thyroid gland is approximately 4 to 4. 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. Substernal goiter article about substernal goiter by the. Substernal goiter may be defined as any thyroid enlargement that has its greater mass inferior to the thoracic inlet. The necessity for a thoracic approach in thyroid surgery. Diagnosis of substernal goiter was confirmed by frontal and lateral chest xray, color ultrasound and ct scan.
This study was carried out to evaluate the clinical presentation, surgical treatment, complications, and risk of malignancy for large substernal goiter. Substernal goiter is a goiter enlarged thyroid gland with intrathoracic extension. Substernal goiters represent up to 7% of mediastinal tumors. The definition of what is a substernal goiter is not clear. Complete total thyroidectomy for substernal goiter duration. Substernal thyroid biopsy using endobronchial ultrasound.
Health, general goiter complications and side effects research morbidity risk factors surgery health aspects methods usage. Morbidity and mortality of thyroidectomy for substernal goiter. Removal of substernal goiter clayman thyroid cancer center. This report is about a large substernal goiter, which was resected via a transcervical and full sternotomy approach. Retrosternal goiter is a common cause of compression of adjacent structures, and it may harbor cancer. Your incidence of carcinomas of 55% is also considerably higher than that in the literature for substernal goiters. Dec 11, 2015 the incidence of substernal goiter is difficult to assess but reportedly ranges from 2. The wide variation is undoubtedly influenced by regional. Retrosternal goiter an overview sciencedirect topics.
Substernal goiter synonyms, substernal goiter antonyms. The antithyroid actions ofwere first investigated in detail when it was noted that patients with psychiatric disease treated with lithium carbonate. Jul 09, 2004 the aim of this study was to evaluate the impact of 1 i therapy on the cervical and the substernal goiter volume, separately. Substernal goiter may be an underrecognized cause of osa. From march 2010 to december 2012, 12 patients with large substernal thyroid goiter who underwent surgery in our department were enrolled in.
A goiter can occur in a gland that is producing too much hormone hyperthyroidism, too little hormone hypothyroidism, or the correct. Contrastenhanced ct of the chest shows a large, contrastenhancing mass in the anterior mediastinum containing calcifications and areas of necrosis. Whether the patient is imaged with the arms overhead or by the side may affect the apparent mediastinal excursion of a goiter. The thyroid gland is located in the forward part of the neck anterior just under the skin and in front of the adams apple. Substernal definition of substernal by the free dictionary. Bilateral recurrent nerve paralysis associated with multinodular substernal goiter. Substernal goiters are generally seen in the 5th decade of life, with a predominance in women.
Substernal goiter surface anatomy, imaging and surgical pictures. Surgical removal of a substernal goiter is a challenging procedure. The patients with the substernal goiter were significantly older, by about a decade, than the patients with enlarged thyroids limited to the neck. Oct 31, 2014 massive substernal goiters can be surgically removed via transcervical approach, thus avoiding sternotomy. Original article, report by ear, nose and throat journal. Contrastenhanced ct of the chest shows a large, contrastenhancing mass in the anterior mediastinum red arrows displacing the trachea white arrow to the right. While the overall incidence in the united states has decreased with the routine use of iodized salt, the development of large multinodular substernal goiters. Epidemiology the incidence of substernal goiter is difficult to assess but reportedly ranges from 2. After patients underwent substernal goiter resection, their positional dyspnea symptoms improved. Surgical treatment of large substernal thyroid goiter 491 int j clin exp med 20. An assessment of free thyroxine index or direct measurement of free. Pdf large substernal thyroid goiter associated with.
The treatment of substernal disease is clearly surgical, but. Clinical presentation and evaluation of goiter in adults. A noncancerous enlargement of the thyroid gland, visible as a swelling at the front of the neck. The wide range in reported incidence is largely due to variation in the definition of substernal goiter.
A large substernal goiter that extended to both sides of. It remains unclear which goitres are to be termed substernal, but a recently proposed definition is a goiter that requires mediastinal exploration and dissection for complete removal or an intrathoracic component extending more than 3 cm in the thoracic inlet 1. Substernal thyroid goiter stg is a slow growing tumor, eventually causing symptoms in 7080% of cases. Surgical management of a substernal goiter sciencedirect.
245 174 676 1117 1554 273 1506 1277 685 826 585 656 182 237 938 1211 409 819 1418 898 116 397 888 550 1090 1127 58 42 1471 17 1483 1504 877 1070 996 635 517 626 251 1186 52 1421 560 1230