Substernal goiters develop for many of the same reasons that a normal goiter develops. Purpose all or part of the thyroid gland may be removed to correct a variety of abnormalities of the gland. Substernal goitre is a disorder of the thyroid gland that frequently requires surgical treatment due to potential compression of adjacent structures and for the exclusion of malignancy. Substernal goiter newman 1995 journal of surgical oncology. Factors influencing extent of surgery for substernal.
Ct scans obtained with the patients arms by the side are more accurate for determining substernal extent of goiter than when the arms are. Thyroid lobectomy with excision of substernal goiter. Pdf 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. The management of a substernal goiter is a problem which has challenged surgeons since its first description in 1749. This type of goiter is associated with tracheal and esophageal compression and during surgery may result in injury to the recurrent laryngeal nerve and vocal fold paralysis. Substernal goiter must be removed surgically due to relation to compressive symptoms, potential airway compromise, and the possibility of an association with thyroid malignancy. Substernal goiter article about substernal goiter by the. Extraction of substernal goitre using an innovative vacuum. Thyroid nodule faculty of medicine siriraj hospital. Successful management of trachea stenosis with massive. Today, substernal goiter is characterized when more than 50% of the gland is extended into the chest, thus requiring dissection of the upper mediastinum. This includes iodine deficiency, thyroid nodule mutations, exposure to radiation or they can be hereditary. Tracheoesophageal compression associated with substernal. In conclusion, although cervical goitres are easily recognised, the initial presentation of mainly substernal goitres may be unusual.
Differential diagnosis, pathology, and treatment of substernal goiter gustaf e. Enlarged thyroid glands ie, goiters often extend in the mediastinum posterior to the sternum, making the gland, by definition, a substernal or retrosternal goiter. 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. 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.
The recurrent laryngeal nerve was identified in the paratracheal area and followed into the entrance into the larynx. We present the extraction of a posterior mediastinal substernal goitre with the application of an innovative vacuumbased suction device, previously used for the control of bleeding. 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. Surgical approach to the substernal goiter request pdf. See clinical presentation and evaluation of goiter in adults, section on goiter with obstructive symptoms or suspected substernal goiter.
Most show continuity with the cervical portion of the gland, although some have only a fibrous band connecting the substernal and cervical thyroid tissues. Cohen p, bhat s, bhat k, song j, akerman m, manjoney dl, kamholz sl. They are rare, representing less than 1% of all rgs secondary rgs develop from the thyroid. When this is the case, they are seen as a large mass in the neck. Extensive mediastinal extension brings the thyroid gland into close quarters. A total of 123 patients with giant nodular goiter sized 620 cm were admitted into our hospital from 1990 to 2011 and the clinical data were retrospectively analyzed. Surgical treatment of large substernal thyroid goiter 489 int j clin exp med 20.
Superior vena cava syndrome and right pleural effusion due. Acute respiratory failure caused by neglected giant. The role of imaging in the diagnosis and surgical approach. Goiter refers to abnormal growth of the thyroid gland.
Many are asymptomatic and incidentally detected on ct as an anterior upper mediastinal mass. A retrosternal or substernal goiter ssg is an enlargement of the thyroid gland that extends into the mediastinum posterior to the sternum. Crosssectional imaging plays an important role both in the diagnosis as well as in the classification of substernal goitre. Substernal thyroids and goiters thyroids which grow into the chest to cause problems. Substernal extension of a goiter into the unyielding thoracic inlet endows a generally benign neck mass with morbid potential.
The thyroid gland is located in the forward part of the neck anterior just under the skin and in front of the adams apple. Surgical management of retrosternal goiter world health. Correlation of symptoms with crosssectional imaging findings volume 121 issue 4 t mackle, j meaney, c timon. Using careful blunt and sharp dissection, the substernal portion of the mass was removed without difficulty. Retrosternal or substernal goitres are extensions of a thyroid goiter behind the manubrium sterni. Substernal goiter, operative approach, ultrasonic knife, complications introduction substernal nodular goiter usually results from simple goiter. Substernal goiter surface anatomy, imaging and surgical pictures. Surgical removal of a substernal goiter answers on healthtap. Haller was the first to describe substernal goiter in 1749 as the extension of thyroid tissue below the upper opening of the chest 1,2. The radiologist needs to be aware of a potential pitfall that can influence the imaging appearance of thyroid goiter. Goiter may be associated with a number of conditionsdiffuse toxic goiter, thyroiditis, thyroid tumor, and sporadic and endemic goiter. Substernal goiter surface anatomy, imaging and surgical. Mri and ct scan revealed that the massive substernal goiter was 9. Usually, they will grow within the neck as shown in the picture of the woman on our goiter page.
In healthy adults without iodine deficiency, a normal thyroid gland is approximately 4 to 4. The thyroid gland is normally located at the front of the neck. Substernal goiter is a goiter enlarged thyroid gland with intrathoracic extension. Substernal goiters are usually extensions of the thyroid into the mediastinum.
The retrosternal substernal goiter majeed h alwan 21 bas j surg, 16, march, 2010 different from that incidence of totally cervical nodular goitre. 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. To study the surgical approaches and operative techniques for substernal goiter. A large substernal goiter as a cause of a pulmonary perfusion defect. This study was carried out to evaluate the clinical presentation, workup, surgical complications, and risk of malignancy for substernal goiter. Clinical presentation and evaluation of goiter in adults. Surgery of substernal goiter md anderson cancer center. Of the 127 patients who had a substernal goiter, 7 ultimately required a sternotomy. The reported incidence of substernal goiter ranges from 2.
Large substernal goiters have presented a challenge to surgeons since the beginning of thyroid surgery. The threat of compression, the substantial chance of malignancy, and the safety of resection mean that the presence of substernal goiter is an indication for surgery. These include a thyroid gland extending 3 cm below the sternal notch or extension of the gland below the fourth thoracic vertebra. Primary intrathoracic goitres arise from aberrant thyroid tissue which is ectopically located in the mediastinum, receive their blood supply from mediastinal vessels and are not connected to the cervical thyroid. 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. Technique of total thyroidectomy for large substernal goiters. Although substernal goiters represent the most common occurring mass of the superior mediastinum and account for 10%15% of all spaceoccupying lesions of the mediastinum, differential diagnosis should be considered for lymphomas, thymomas, pleuropericardial cysts, dermoid cysts, and neurogenic tumors 6. Between 1992 and 2005, 59 patients underwent surgery for substernal goiter at our institution. 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. Substernal goiter sg was first described by haller in 1749 and first surgically removed by klein in 1820. Substernal goiter occurs when the thyroid gland or masses within the gland extend into the upper chest.
Whether the patient is imaged with the arms overhead or by the side may affect the apparent mediastinal excursion of a goiter. A critical analysis of 33 patients with substernal goiter. These patients underwent total or subtotal thyroidectomy. Patients with substernal goiter, age pdf please select a format to send. A retrosternal goiter often causes no symptoms for years.
Substernal thyroid goiter extension of a thyroid goiter arising in the neck inferiorly into the thorax is relatively uncommon most 7580% arise from lower pole or isthmus of the thyroid and extend into anterior mediastinum. 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. Removal was almost always accomplished via cervical incision, with low morbidity and no deaths. The wide variation is undoubtedly influenced by regional endemic goiter belts and referral patterns, as most series have been collected at tertiary care institutions. Diagnosis of substernal goiter was confirmed by frontal and lateral chest xray, color ultrasound and ct scan. 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. 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. Thyroid volume measured by ultrasonography is slightly greater in men than women, increases with age and body weight, and decreases. Retrosternal goiter an overview sciencedirect topics. Thyroidectomy definition thyroidectomy is a surgical procedure in which all or part of the thyroid gland is removed.
An innability to discover the base of the thyroid gland is suggestive of a substernal goiter. Abstract the management of a substernal goiter is a problem which has challenged surgeons since its first description in 1749. The extraction by cervicotomy of substernal goitres may be impossible and sometimes requires the enlargement of the thoracic inlet with at least a sternalsplit. An unusual cause of respiratory failure after coronary artery bypass grafting. Patients with longstanding goiters cervical or substernal may develop symptoms of obstruction due to progressive compression of the trachea or sudden enlargement usually accompanied by pain secondary to hemorrhage into a nodule.
However, the incidence of cancer in patients with ssg is reported in several studies to be between 2. The patients with the substernal goiter were significantly older, by about a decade, than the patients with enlarged thyroids limited to the neck. Even though a cervical surgical approach is sufficient in the vast majority of cases. There is no uniform, widely accepted definition of ssg. Request pdf surgical approach to the substernal goiter surgery for substernal goiters can be technically demanding. Original article surgical treatment of large substernal. One article has identified at least six different definitions 1 that may help explain why the prevalence of ssg ranges anywhere from 2%19% among. In this article we report the diagnosis, symptoms, thyroid function, treatment, and postoperative complications of 59 patients with substernal goiter. To summarize the experience in the perioperative treatment of giant nodular goiter methods. Except for lymphomas, prognosis was good after resection.
Substernal thyroid goiter aka retrosternal, intrathoracic, mediastinal any goiter in which at least 50% of the thyroid lies below the level of the thoracic inlet first described by haller in 1749 first successfully resected by klein in 1820. The treatment of substernal disease is clearly surgical, but. In some cases, the chest needs to be surgically opened to remove these goiters, which is a more extensive and invasive operation. Truly ectopic mediastinal goiters are rare, and most substernal goiters arise from and maintain some attachment to the cervical thyroid gland. A retrosternal thyroid refers to the abnormal location of all or part of the thyroid gland below the breastbone sternum. A retrosternal goiter is always a consideration in people who have a mass sticking out of the neck. There is general agreement that medical treatment is ineffective for substernal goiters. Doctors give trusted, helpful answers on causes, diagnosis, symptoms, treatment, and more. A retrospective study of 27 cases with substernal thyroid nodules was made in our hospital. A new classification system for retrosternal goitre based on a. Substernal goiter is defined as a thyroid mass of which more than 50% is located below the thoracic inlet.
Retrosternal goiter rsg is a term that has been used to. Surgical management of a substernal goiter sciencedirect. Massive substernal goiter michael klein, md suny downstate medical center may 19, 2016. Thyroid hormone t480ug d produced by the thyroid gland t330ug d. 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. Some of these substernal goiters will remain small, and due to their location, they may not be noticed unless they become symptomatic. Substernal definition of substernal by the free dictionary. Full text get a printable copy pdf file of the complete article 650k, or click on a page image below to browse page by page. Retrosternal goiter can cause respiratory distress, dysphagia, compression of great vessels, and even sudden death. Compression syndromes caused by substernal goitres. When thyroids get enlarged called a goiter, they can grow a number of different directions. Although bilateral glands are often involved, the large lesions are usually located in unilateral gland. A case of 65 yearold chinese male patient with severe tracheal stenosis due to a massive substernal goiter, is presented. Tracheoesophageal compression associated with substernal goitre.
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