Resection of a giant bilateral retrovascular intrathoracic goiter causing severe upper airway obstruction, 2 years after subtotal thyroidectomy: a case report and review of the literature

Abstract

The intrathoracic (or substernal) goiter is more often benign; but it can be malignant in 2-22% of patients. There is history of prior thyroid surgery in 10% to more than 30% of patients. Intrathoracic goiters cause adjacent structure compression more frequently than the cervical goiters, due to the limited space of the thoracic cage. Compression of trachea, oesophagus, vascular and neural structures may cause dyspnoea, dysphagia, superior vena cava syndrome, subclavian vein thrombosis, hoarseness, and Horner's syndrome. There is usually progressive deterioration, but acute exacerbation may occur. The presence of a thoracic goiter (>50% of the mass below the thoracic inlet) is per se an indication for resection. Tracheal compression by (cervical or thoracic) goiter is also an indication for resection; early tracheal decompression is recommended particularly in symptomatic patients. In severe respiratory distress, intubation and semi-urgent operation may be required. With early intervention, most intrathoracic goiters can be removed through a cervical approach, while tracheomalacia is avoided. We hereby present successful and uncomplicated total thyroidectomy, through a median sternotomy, of a benign, gigantic, bilateral, retrovascular, posterior mediastinal, intrathoracic goiter, encircling the trachea, and causing severe respiratory distress in a 63 year old man with history of previous subtotal thyroidectomy.

Keywords: Airway obstruction/etiology; airway obstruction/surgery; goiter; goiter/intrathoracic; substernal/surgery; thyroidectomy.

Video 1

intrathoracic (or substernal) goiter

Figure 1

Preoperative chest x-ray. Enlargement of the upper and middle mediastinum (white arrows), mild tracheal deviation to the right, and tracheal stenosis, at the level of the aortic arch (black arrows).

Figure 2

Preoperative thoracic computed tomography. A large prespinal superior and posterior mediastinal mass. Two retrovascular, pre- para- and retro-tracheal lobes are displacing the aortic arch, the anonymous vein, and the trachea, descending to the hila, severely compressing the trachea at the level of the aortic arch.

Figure 3

The right lobe has just been delivered from the mediastinum, intact and encapsulated (enucleated).

Figure 4

Total thyroidectomy was performed through a median sternotomy combined with a cervical collar incision. The 2 lobes were enucleated and delivered from the mediastinum completely intact. The total specimen weight was 290 gr, the maximum length of the right lobe was 12 cm, and the maximum length of the left lobe was 14 cm.

Figure 5

Postoperative chest x-ray, on the 8^th postoperative day (the day before discharge). Very satisfactory recovery, without cardiorespiratory complications. Mild residual tracheal stenosis and deviation, attributed to tracheomalakia due to chronic compression, remained. No further intervention was required.

Figure 6

Computed tomography, 1 month postoperatively. Clinically insignificant residual tracheal stenosis, at the level of the aortic arch.

Figure 7

Computed tomography, 6 months postoperatively. Excellent tracheal patency with some distortion of its lumen (increased anteroposterior and decreased transverse diameter at the level of the aortic arch, where severe stenosis was present preoperatively). Complete goiter resection, absence of recurrence.

Figure 8

Comparison of preoperative and postoperative thoracic computed tomographies. Notice the degree of tracheal compression and the displacement of the aortic arc preoperatively (up). Anatomy restored postoperatively (down).