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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 102-104

Humongous mediastinal goiter: Interesting case report with its management challenges


1 Department of Endocrine and Metabolic Surgery, Endocare Hospital, Vijayawada, Andhra Pradesh, India
2 Amar Bariatric and Advanced Laparoscopy Centre, Hyderabad, Telangana, India
3 Department of Endocrine Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India

Date of Submission30-Jun-2020
Date of Acceptance24-Mar-2021
Date of Web Publication07-Aug-2021

Correspondence Address:
Dr. R B Panchangam
Consultant Endocrine and Metabolic Surgeon, Ex-Associate Professor of Surgical Endocrinology, Endocare Hospital, Vijayawada, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_32_20

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  Abstract 


Goiters with mediastinal extension are very rare. Occasionally they necessitate thoracic exploration for complete surgical excision which may be associated with serious complications. A 50-year-old man presented with a simple multinodular goiter and huge thoracic extension. After adequate investigative workup and optimal preoperative preparation, he underwent successful total thyroidectomy via combined cervicotomy and complete sternotomy. The excised goiter was 1.85 kg in weight and 20 × 25 × 18 cm in dimensions occupying entire anterosuperior mediastinum and 60% of left pleural cavity. Postoperative recovery was uneventful with no major morbidity. Rarely, giant thoracic extensions such as this case can be encountered. We are arguably reporting one of the largest thoracic goiters ever reported.

Keywords: Goiter, mediastinal goiter, sternotomy, thoracotomy, thyroidectomy


How to cite this article:
Panchangam R B, Vennapusa A, Mayilvaganan S. Humongous mediastinal goiter: Interesting case report with its management challenges. Arch Int Surg 2020;10:102-4

How to cite this URL:
Panchangam R B, Vennapusa A, Mayilvaganan S. Humongous mediastinal goiter: Interesting case report with its management challenges. Arch Int Surg [serial online] 2020 [cited 2021 Dec 3];10:102-4. Available from: https://www.archintsurg.org/text.asp?2020/10/3/102/323463




  Introduction Top


Goiters with mediastinal extension are very rare. Majority of cases have been operated through cervical approach, but occasionally they necessitated thoracic exploration for complete surgical excision. Rarely, giant thoracic extensions may be encountered. In this article, we described and discussed the management of a giant thoracic goiter, the largest in our experience.


  Case Report Top


A 50-year-old man consulted us with history of anterior neck swelling of 3 years durations. His physique was not obese and had no short neck. He also complained of progressive difficulty in breathing and heaviness in chest for 6 months. There was no history of hypertension, diabetes, chronic respiratory illness, cardiac disease, or allergy. On examination, there was grade III multinodular goiter with an indistinct lower border. There was no regional cervical lymphadenopathy. A dull note was elicited on percussion of anterior mediastinum and chest wall. Pemberton's sign was positive. With the provisional diagnosis of large multinodular goiter with retrosternal extension, preoperative workup was performed. Chest X-ray, ultrasound-guided fine-needle aspiration cytology (FNAC) from a solid nodular part of cervical part of goiter, and contrast-enhanced computerized tomography (CECT) of neck and chest were performed apart from routine biochemistry, serology, and thyroid profile. Serum TSH was 4.0 mIU/L (0.35–4.0) and FNAC was colloid goiter with no evidence of malignancy.

In addition to the cervical goiter, we found a very huge mediastinal and thoracic goiter extending from cervical mass. Thoracic component was occupying all of anterosuperior mediastinum and almost 60% of left chest cavity up to 4th intercostal space displacing the middle mediastinal structures towards right side. The thoracic mass was heterodense and 25 × 18 × 22 cm in dimensions with clear tissue planes around [Figure 1]a. There was a large thoracic extension of the cervical goiter to the mediastinum and thoracic cavity [Figure 1]b and a chest radiograph revealed a radio-opaque mass correlating to the lesion [Figure 1]c. Our final clinical diagnosis was nontoxic benign multinodular goiter with huge thoracic extension.
Figure 1: (a) Axial section of CECT chest shows heterodense mass occupying left thoracic cavity and pushing middle mediastinum to right side; (b) Coronal section of CECT shows large thoracic extension of cervical goiter to mediastinum and thoracic cavity; (c) Plain chest radiograph shows radio-opaque mass correlating to CT lesion

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After preoperative optimization, chest physiotherapy, spirometry, prophylactic antibiotics, and steroids (dexamethasone 1.0 mg/day for 3 days), we prepared the patient for surgical total thyroidectomy. Under general inhalational anesthesia with transoral endotracheal intubation, initial total thyroidectomy was performed with conventional open cervicotomy. As per prior plan, T incision was given and we did complete vertical sternotomy [Figure 2]a. Through this wound, entire thoracic mass was meticulously separated from mediastinal structures, pericardium, and lungs [Figure 2]b. Mediastinal pleura had to be incised on both sides for adequate mobilization and complete excision of goiter [Figure 3]a. Phrenic nerves on both sides were safeguarded and sternotomy wound closure effected with stainless steel sutures [Figure 3]b. The excised thoracic mass corresponded to the CT lesion [Figure 4]a and the weight of entire excised goiter (including both cervical and thoracic part) was 1.85 kg. Cervical component (150 g) was much smaller than thoracic part. Postoperatively, patient was reversed from anesthesia but maintained on endotracheal intubation in situ and T piece ventilation with 6 L/min oxygen flow for 24 h. After extubation, he had no tracheomalacia or stridor. Postoperative period was uneventful with recovery of pulmonary function [Figure 4]b. Histopathology was reported as benign adenomatous goiter with no evidence of any malignancy. Postoperatively, he was placed on empirical thyroxine replacement of 125 mcg per day, and the dosage was titrated at three monthly intervals to maintain serum TSH within normal limits. He was followed up for 12 months. He had no recurrence or any morbid sequelae.
Figure 2: (a) Surgical exploration via sternotomy showing a huge vascular goitrous mass; (b) Dissection of goiter mass and separation from mediastinal structures

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Figure 3: (a) Surgical field after excision of mass showing normal trachea and great vessels at root of the neck in a bloodless field; (b) Sternotomy wound closure with stainless steel sutures

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Figure 4: (a) Ex vivo bisected specimen of surgically excised giant thoracic mass corresponding to CT lesion; (b) Postoperative chest radiograph shows normally expanded left thoracic cavity (with chest drain in situ and normally placed mediastinal structures)

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  Discussion Top


Goiter with mediastinal extension constitutes about 5.7%[1] though the incidence ranges between 1% and 25% depending upon the inclusion criteria. Majority of them can be operated by cervical approach. But, occasionally mediastinal goiters pose anesthetic and surgical challenges, necessitating thoracic approach.[2] Advances in minimal access and thoracoscopic surgery have facilitated thoracoscopic thyroidectomy in few cases. Mediastinal goiters can be operated via neck, sternotomy (partial or total), claviculotomy, anterior thoracotomy, postero lateral thoracotomy, or video-assisted thoracoscopy.[3] Surgical exploration of thorax for excision of goiters is especially challenging for surgical team due to close relationship with vital mediastinal structures such as pleura, trachea, pericardium, phrenic nerve, and great blood vessels. Moreover, recurrent laryngeal nerves are in precarious position due to distortion and displacement by goiter. Thus, surgeon and assistants should be highly skilled and experienced in dealing with these cases. Anesthesia and postoperative care are also risky because of high chances of compressive tracheomalacia, difficult intubation due to deviation of larynx and trachea, and risk of laryngeal edema due to submucosal venous and lymphatic congestion due to long standing thoracic outlet obstruction. Fortunately, we did not encounter any of these complications due to adequate preparation and delayed extubation. Several reports justify the utility of delayed extubation and elective T piece ventilation in obviating tracheal related complications. From patient point of view, we need extensive psychological and physiological preparation through counseling, chest physiotherapy, spirometry, adequate hydration, steroid cover, and antibiotics. Advantages of steroid use to obviate perioperative respiratory morbidity are well documented in literature.[4] There is high risk of tracheostomy, recurrent laryngeal nerve palsy, hypoparathyroidism, phrenic nerve injury, bleeding, and injury to mediastinal structures. Fortunately, we faced none of these morbidities due to meticulous surgery. To the best of our knowledge and searched literature, it is probably the world's largest goiter in the retrosternal region. There have been reports of heavier and larger goiters, but they are mostly cervical and exophytic goiters from endemic areas up to 6 kg.[5],[6] Among thoracic goiters, our case is the largest goiter and it is unlikely to have such larger than this in thorax because of finite space and presence of vital cardio-respiratory structures critical for healthy life. Early diagnosis, optimal diagnostic investigations, good preoperative preparation (especially pulmonary function), surgical planning, expert surgeon-anesthetic team, and meticulous intra and postoperative protocol are mandatory for the successful cure of these rare cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Allo MD, Thompson NW. Rationale for operative management of substernal goiters. Surgery 1983;94:969-77.  Back to cited text no. 1
    
2.
Andrade MA. A review of 128 cases of posterior mediastinal goiter. World J Surg 1977;1:789-97.  Back to cited text no. 2
    
3.
Bhargav PR, Bhagat SD, Kishan Rao B, Murthy SG, Amar V. Combined cervical and video-assisted thoracoscopic thyroidectomy (CAVATT): A simplified and innovative approach for goiter with posterior mediastinal extension. Indian J Surg 2010;72:336-8.  Back to cited text no. 3
    
4.
Roberts RJ, Welch SM, Devlin JW. Corticosteroids for prevention of postextubation laryngeal edema in adults. Ann Pharmacother 2008;42:686-91.  Back to cited text no. 4
    
5.
Gao B, Jiang Y, Zhang X, Zhao J, He Y, Wen Y, et al. Surgical treatment of large substernal thyroid goiter: Analysis of 12 patients. Int J Clin Exp Med 2013;6:488-96.  Back to cited text no. 5
    
6.
Nada A, Ahmed AM, Vilallonga R, Armengol M, Moustafa I. A giant euthyroid endemic multinodular goiter with no obstructive or compressive symptoms. Case Rep Med 2011;2011:620480. doi: 10.1155/2011/620480.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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