An overview of retrosternal goiter.

Goiters tend to grow slowly and steadily over many years, occasionally reaching the mediastinum and extending through the thoracic inlet into the visceral compartment. In most cases, retrosternal goiters originate from the cervical portion of the thyroid. The incidence of retrosternal goiters varies considerably, ranging from 0.2 to 45% of all thyroidectomies, depending on the criteria used to define this type of goiter. Symptoms are generally related to the compressive nature of the mass on the adjacent structures, and most patients report some form of respiratory manifestation associated with the goiter. A diagnostic assessment usually includes an evaluation of thyroid function, chest radiography, and computed tomography. Fine-needle aspiration biopsy should be avoided in substernal areas of the goiter due to limited visibility and location of vital structures in this region. Treatment of retrosternal goiters is surgical, as medical therapy is generally unsuccessful in these cases.

fT3:fT4 ratio in Graves' disease - correlation with TRAb level, goiter size and age of onset.

INTRODUCTION: Graves' Disease (GD) is an autoimmune hyperthyroidism occurring mostly in young women. The main pathogenic role of the disease is attributed to TSH receptor antibodies (TRAb), which stimulate the thyroid gland to increase production of the most active thyroid hormone- triiodothyronine (T3). High level of TRAb and a large goiter size are commonly known as poor prognostic factors for the disease and are used to predict relapse. THE AIM: The purpose of our study was to check the correlation between fT3:fT4 ratio with TRAb concentration, total volume of thyroid and age of GD onset. MATERIALS AND METHODS: 114 patients with onset or relapse of GD were analyzed. Those after thyroidectomy or radioiodine therapy were not taken into analysis. The data was retrospectively retrieved from the hospital's records consisting of patients' sex, age, level of TRAb, fT3, fT4 and thyroid volume on ultrasonography. The association between fT3:fT4 and TRAb concentration, thyroid volume and age was evaluated using Pearson correlation coefficient. RESULTS: The group was predominated by women (19.3% men, 80.7% women). The average age was 47.0. The analysis revealed positive correlation between: 1) fT3:fT4 ratio and total volume of thyroid (correlation ratio: 0.37; p <0.05) 2) fT3:fT4 ratio and level of TRAb (correlation ratio: 0.26; p or <0.05) 3) negative correlation between fT3:fT4 ratio and patient's age (correlation ratio: -0.14; p = 0.144). CONCLUSIONS: Positive correlations between fT3:fT4 ratio and TRAb level and total volume of thyroid (poor predictors of GD) may confirm that high level of fT3 can also be a prognostic factor for GD severity.

[Een rood en gezwollen gelaat na heffen van de armen]. / Een rood en gezwollen gelaat na heffen van de armen.

An 82-year-old woman attended our outpatient clinic because of a swollen right arm and hoarseness. Upon raising both arms, the patient developed a red and swollen face (Pemberton's sign). An MRI of the thorax showed a large intrathoracic goitre, which compressed venous structures and limited blood flow even when she lowered her arms.

Cough syncope and tracheal compression secondary to a retrosternal goitre: looking for a pulmonary embolism.

A 51-year-old man presented acutely with recurrent bouts of coughing associated with transient and brief loss of consciousness consistent with cough syncope, mild stridor and a recent history of a respiratory tract infection. A chest X-ray demonstrated tracheal narrowing. His D-dimer was negative. A non-contrast CT scan of the chest demonstrated a large retrosternal goitre causing tracheal compression, and further investigation with a contrast-enhanced CT scan of the neck and chest demonstrated an incidental finding of a large pulmonary embolus (PE). The full extent of the PE was determined through performing a CT pulmonary angiography. Doppler ultrasound demonstrated a left leg deep vein thrombosis as the primary cause of the PE. His cough syncope improved in response to anticoagulation treatment, to the point where he could be safely discharged home. He had a further significant improvement in symptoms following an elective hemithyroidectomy for retrosternal goitre.

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.

Substernal goiter and laryngopharyngeal reflux.

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.

Bocio endotorácico como causa infrecuente de síndrome de vena cava superior / Endothoracic goitre as an uncommon cause of superior vena cava syndrome

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Pemberton Sign: A Recommendation to Perform Arm Elevation Spirometry With Flow-Volume Loops.

We report a case of intrathoracic goiter with positive Pemberton sign. Conventional spirometry did not show abnormalities, but arm elevation spirometry with flow-volume loops revealed expiratory flow limitation with a plateau. Clinicians should consider repeating flow-volume loops with arm elevation in all cases of intrathoracic goiter with initially normal loops.

Desviación traqueal en radiografía de tórax / Tracheal curvature in chest X-ray

Paciente varón de 67 años de edad que acude a consulta de atención primaria con sintomatología de astenia, anorexia, progresiva pérdida de peso, así como disnea de medianos esfuerzos. No refiere síntomas aparentes de insuficiencia cardiaca, no presenta disfagia ni disfonía y no tiene fiebre. En la Radiografía simple de tórax se observa una compresión y desviación de la columna de aire traqueal hacia el lado derecho y discreta hiperinsuflación de ambos campos pulmonares. Se realiza Ecografía en el Centro de Salud apreciando un bocio intratorácico, no se encuentran otras alteraciones en mediastino(AU)

A 67 year old male patient sought medical attention at a primary health centre with symptoms of asthenia, anorexia, progressive weight loss, along with dyspnea upon slight exertion. He did not show symptoms of heart failure, did not present dysphagia or dysphonia and did not have fever. In a simple chest X-ray, compression and right curvature of the tracheal air column and discreet overinflation of both lung fields could be seen. An ultrasound scan was carried out at the health centre and intrathoracic goitre was visible. No other alterations in the mediastinum were found(AU)

Upper airway obstruction in patients with endothoracic goiter enlargement: no relationship between flow-volume loops and radiological tests.

BACKGROUND: In about 16-85% of subjects with goiter, upper airway obstruction (UAO) is observed. This percentage is higher in patients affected by goiter with endothoracic enlargement. UAO is an indication for surgery. Visual analysis of flow-volume loops (FVL) are the best indicators for UAO, although various studies using clinical and radiological parameters have observed no correlation. OBJECTIVE: To evaluate the presence of UAO in patients with endothoracic goiter enlargement and the relationship between the FVL with the observed symptoms and the measurements obtained by computed tomography (CT). SUBJECTS: Subjects with endothoracic goiter enlargement participated in the study. DESIGN: i) Symptom questionnaire (dysphagia, dyspnea, cough, oppression, dysphonia, and worsened symptoms when prone); ii) analysis: TSH and free thyroxine; iii) cervical ultrasound; iv) cervical-thoracic CT (measurements of area and diameter in the area of maximum stenosis and at 2 cm from the carina); v) chest radiography and vi) forced spirometry: visual analysis of FVL morphology and the maximum forced expiratory volume in 1 s (FEV(1)), forced expiratory flow at 50% vital capacity/forced inspiratory flow at 50% vital capacity and FEV(1)/peak expiratory flow parameters. RESULTS: Fifty subjects participated in the study: 11 men/39 women, median age 73.8 years (43.76-88.43). UAO was diagnosed in 13 cases (26%, confidence interval: 14.6-40.3%) and 27 subjects (54%) presented symptoms suggesting goiter compression. No clinical or radiological variables showed the presence of UAO. CONCLUSIONS: The frequency of UAO in subjects affected by goiter with endothoracic enlargement was lower than that described for goiter patients, and there were no clinical or radiological indicators to establish its presence.

Orthopnea and tidal expiratory flow limitation in patients with euthyroid goiter.

BACKGROUND: Nontoxic goiters can cause extrathoracic upper airway obstruction and, if large, may extend into the thorax, causing intrathoracic airway obstruction. Although patients with goiter often report orthopnea, there are few studies on postural changes in respiratory function in these subjects. PURPOSE: The aim of this study was to investigate the postural changes in respiratory function and the presence of flow limitation (FL) and orthopnea in patients with nontoxic goiter. METHODS: In 32 patients with nontoxic goiter, respiratory function was studied in seated and supine position. Expiratory FL was assessed with the negative expiratory pressure method. Goiter-trachea radiologic relationships were arbitrarily classified as follows: grade 1, no evidence of tracheal deviation; grade 2, tracheal deviation present in lateral and/or anteroposterior plane but with tracheal compression < 20%; and grade 3, tracheal deviation present with compression > 20%. Subgroups were considered according to this classification and occurrence of orthopnea and FL. RESULTS: In all three groups of patients, the average maximal expiratory flow at 50% of FVC/maximal inspiratory flow at 50% of FVC ratios were > 1.1, suggesting the presence of upper airway obstruction. Grade 3 patients had a significantly lower expiratory reserve volume and maximal expiratory flow at 25% of FVC and higher airway resistance and 3-point FL score than patients with grade 1 and grade 2. The prevalence of orthopnea was highest in patients with grade 3 (75%, as compared to 18% in the grade 1 group). In patients with orthopnea, the prevalence of intrathoracic goiter was also higher (78%, vs 21% in patients without orthopnea). CONCLUSION: There is a high prevalence of orthopnea in patients with goiter, especially when the location is intrathoracic and causes a reduction of end-expiratory lung volume and flow reserve in the tidal volume range, promoting FL especially in supine position. Obesity is a factor that increases the risk of orthopnea in patients with goiter.

Identification of the non-recurrent inferior laryngeal nerve using intraoperative neurostimulation.

INTRODUCTION: The non-recurrent inferior laryngeal nerve occurs at a frequency of about 0.5% and usually on the right side. The identification of a non-recurrent laryngeal nerve may be difficult. We describe a new method for its identification using intraoperative neurostimulation. METHODS: We examined nine patients with a non-recurrent inferior laryngeal nerve and five patients with a normal inferior laryngeal nerve anatomy who were operated on trans-sternally. Neurostimulation of the vagal nerve producing electromyographic signal in the intrinsic laryngeal musculature was performed at different points proximally and distally. RESULTS: : Electromyographic signals were found proximally but not distally of the separation of the inferior laryngeal nerve from the vagus in 14 patients. In nine patients with a non-recurrent inferior laryngeal nerve, we performed neurostimulation of the vagus opposite the lower and the upper thyroid poles. In all patients we found no electromyographic signals at the distal stimulation point. In contrast, proximal neurostimulation of the vagus opposite the upper thyroid pole produced positive electromyographic signals. CONCLUSION: Neurostimulation of the vagal nerve distally of the separation of the inferior laryngeal nerve did not produce electromyographic signals in the intrinsic laryngeal musculature, perhaps due to the different modalities in the vagal fascicles. Negative electromyographic signals following neurostimulation of the distal vagal nerve opposite the lower thyroid pole should lead to proximal neurostimulation of the vagus opposite the upper thyroid pole. Positive electromyographic signals proximally and negative electromyographic signals distally predict the occurrence of a non-recurrent inferior laryngeal nerve which allows its diagnosis before surgical dissection of the thyroid gland and may prevent nerve palsy.

Retrosternal goiter: a six-year institutional review.

Retrosternal goiter is defined as any goiter in which at least 50 per cent of the thyroid resides below the level of the thoracic inlet. The incidence of retrosternal goiter varies from 3 to 20 per cent with respect to thyroidectomy patients. A retrospective chart review from June 1991 to December 1997 found 232 thyroidectomies performed at our institution. Sixteen patients were found to have retrosternal goiters (6.9%). The mean age was 57.8 years (range, 34-92). All were of benign pathology. Symptoms included shortness of breath (68.8%), hoarseness (37.5%), dysphagia (31.3%), and superior vena cava obstruction (6.25%). Thirteen patients were female (81.3%). Fifteen patients had surgical intervention (93.8%). Total thyroidectomy was performed in nine cases (60%), whereas lobectomy was performed in six cases (40%). All treated patients had complete resolution of symptoms. A cervical incision alone was used in 13 cases (86.7%). Complications consisted of one postoperative pleural effusion and in one case a traumatic C5 nerve root compression occurred. There were no instances of long-term vocal cord paralysis or hypoparathyroidism. There was no perioperative mortality. In the majority of patients with retrosternal goiter, surgery can be done expeditiously through a cervical incision with minimal morbidity and mortality.

[Intrathoracic goiters. 62 surgically treated patients]. / Les goitres endothoraciques. 62 malades opérés.

OBJECTIVES: Intrathoracic goitres present as tumors of the upper mediastinum. Malignancy is uncommon, but sudden or progressive development often leads to compression of the trachea. We report here our experience with surgical exeresis. METHODS: From 1980 to 1995, we operated 62 patients with intrathoracic goitre. There were 23 men and 39 women (mean age 63 years). The main manifestations leading to diagnosis were dyspnea (n = 20; 32%) and identification of a mediastinal formation on routine chest x-rays (n = 19; 30%). RESULTS: Antevascular goitre was seen in 24 patients (39%) and retrovascular goitre in 38 (61%). The retrovascular goitres were located anteriorly and laterally to the trachea in 21 patients (34%) and posteriorly in 17 (27%). Simple cervicotomy was used in 57 patients (92%). Manubriotomy (n = 1) and total sternotomy (n = 4) were also required. All intrathoracic goitres removed were benign. Post-operative mortality was nul and morbidity was 11%: 2 cases of hypocalcemia and 2 tracheomalacias including 1 with recurrent nerve palsy and one with hematoma and pulmonary infection. CONCLUSION: Surgical exeresis of intrathoracic goitre is essentially required in case of respiratory distress due to compression of the trachea. Morbidity is low with simple cervicotomy.

Peak expiratory flow in the detection of retrosternal goitre.

In 24 patients where the lower border of a cervical goitre was poorly defined, the value of simple lung function tests in the prediction of the presence of a retrosternal goitre was assessed. At operation there were nine patients with retrosternal extension (Group I) and 15 without (Group II). The preoperative PEF ratio (observed to predicted) was significantly different between the two groups (P = 0.004) with a positive predictive value of 90% for a retrosternal goitre. This difference was abolished after thyroidectomy. There was a significant improvement in PEF in patients with retrosternal goitres after thyroidectomy (P less than 0.001). It is concluded that the preoperative measurement of PEF is a simple method of detecting the retrosternal extension of a cervical goitre.