1
|
Enny L, Garg S, Mouli S, Manjunath S, Singh KR, Ramakant P, Mishra AK. Effect of Thyroidectomy on Tracheal Remodeling and Airway Physiology in Apparently Asymptomatic Patients with Goiter: A Prospective Study. World J Surg 2023; 47:3222-3228. [PMID: 37787777 DOI: 10.1007/s00268-023-07192-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Tracheal airflow limitation is frequently reported in patients with goiter but is severely underestimated, and studies on how goiter and its treatment affect trachea are scarce. Moreover, the choice of the optimal treatment for individual patient with asymptomatic goiter is not straightforward. Therefore, in this study we aim to investigate the effect of goiter and subsequent thyroidectomy on tracheal anatomy and change in airflow in asymptomatic patient with goiter. METHODS Seventy patients undergoing total/hemithyroidectomy (TT/HT) from Feb 2020 to Feb 2021 satisfying inclusion criteria were enrolled in the study. Neck radiograph (NR) and forced spirometry (FS) were performed preoperatively and on postoperative day 10 and 6 weeks and 3 months. RESULTS Out of 70 patients, 84.3% patients were female, and mean duration and weight of goiter were 54.7 months and 72.21 gm, respectively. Of 70 patients, 57 were of benign pathology. Significant improvement in tracheal compression with moderate improvement in deviation was observed after surgery. Preoperative spirometry showed significant reduction in almost all parameters. After surgery, a weak improvement was observed at postoperative day 10 and 6 weeks; however, significant improvement in FEV1, PEFR, FEV1/FEV0.5, and FEF50%/FIF50% was observed at postoperative 3 months. Patient with right sided and those with ≥ 8 mm deviation were associated with poorer pulmonary function. Weak correlation was observed between neck NR and spirometry parameters. Weight of the thyroid gland significantly correlated with ratio of MVV/FEV1. CONCLUSION Patients with asymptomatic goiter can have significant abnormal changes in airflow as evidenced by FS and NR. Thyroidectomy is followed by gradual restoration of tracheal deviation and compression with significant improvement in pulmonary airflow.
Collapse
Affiliation(s)
- Loreno Enny
- Department of Endocrine Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Surabhi Garg
- Department of Endocrine Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sasi Mouli
- Department of Endocrine Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Shreyamsa Manjunath
- Department of Endocrine Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Kul Ranjan Singh
- Department of Endocrine Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Pooja Ramakant
- Department of Endocrine Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India.
| | - Anand Kumar Mishra
- Department of Endocrine Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
| |
Collapse
|
2
|
Chakravarty S, Nagarkar NM, Ghosh A, Mehta R. Retrosternal Thyroid with Mediastinal Extension: Surgical Approach and Management. Indian J Otolaryngol Head Neck Surg 2023; 75:332-337. [PMID: 37275118 PMCID: PMC10235387 DOI: 10.1007/s12070-022-03231-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022] Open
Abstract
To assess the clinical presentation and the need for sternotomy as an additional approach for surgical excision of goitre with retrosternal extension. It was a retrospective review of 22 patients (13 female, 9 male; mean age: 50.36 years) who underwent total thyroidectomy for retrosternal extension. Between-group differences were assessed using Chi-square or Fisher exact test, appropriate P values < 0.05 were considered indicative of statistical significance. All cases were assessed by CT scan of neck and thorax to confirm mediastinal extension. The symptoms most commonly reported were dyspnoea 6 (27%), hoarseness (13%) and dysphagia 2 (9%). The retrosternal extent was grade 1(thoracic inlet to aortic arch) in 11 cases and grade 2(aortic arch to pericardium) in 11 cases. Overall, 13 (59%) patients showed CT evidence of tracheal deviation. Patients were divided into two groups based on the surgical approach: trans-cervical (n = 13) and trans-cervical plus trans-sternal (n = 9). The radiological extent of retrosternal descent of goitre in the mediastinum showed no significant correlation with the requirement of sternotomy in our cohort (odds ratio for sternotomy in grade 2 extension: 1.45). The need for sternotomy in cases of retrosternal thyroid does not depend on the radiological extent of tumour alone. It depends on multitude of factors like presence of dysphagia, dyspnoea or hoarseness. Preservation of recurrent laryngeal nerve and parathyroid glands is difficult in the restricted thoracic inlet space. Sternotomy is required for complete excision and preservation of major mediastinal vessels.
Collapse
Affiliation(s)
- Sharmistha Chakravarty
- Department of ENT & Head Neck Surgery, All India Institute of Medical Sciences, G.E Road, Tatibandh, Raipur, C.G 492099 India
| | - Nitin M. Nagarkar
- Department of ENT & Head Neck Surgery, All India Institute of Medical Sciences, G.E Road, Tatibandh, Raipur, C.G 492099 India
| | - Amritava Ghosh
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, G.E Road, Tatibandh, Raipur, C.G 492099 India
| | - Rupa Mehta
- Department of ENT & Head Neck Surgery, All India Institute of Medical Sciences, G.E Road, Tatibandh, Raipur, C.G 492099 India
| |
Collapse
|
3
|
Abstract
Retro-sternal goitres are slow growing in nature. Dyspnoea on exertion is the most common presenting symptom due to the pressure effect of goitre on trachea. Due to the increased use of radiological investigations, retrosternal goitres are often diagnosed incidentally without any symptoms. Surgical resection is considered the gold standard management in all symptomatic patients and most of asymptomatic patients. However, "wait and watch" approach is an option, in selected asymptomatic patients, with the evolution of alternative treatment methods. So, the management of retrosternal goitre continues to be a surgical controversy. This article aims at reviewing the evidence-based practice of management of retrosternal goitres including challenges of surgery and postoperative complications.
Collapse
|
4
|
Tanaka A, Uchiyama A, Horiguchi Y, Higeno R, Sakaguchi R, Koyama Y, Ebishima H, Yoshida T, Matsumoto A, Sakai K, Hiramatsu D, Iguchi N, Ohta N, Fujino Y. Predictors of post-extubation stridor in patients on mechanical ventilation: a prospective observational study. Sci Rep 2021; 11:19993. [PMID: 34620954 PMCID: PMC8497593 DOI: 10.1038/s41598-021-99501-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/24/2021] [Indexed: 12/17/2022] Open
Abstract
The cuff leak test (CLT) has been widely accepted as a simple and noninvasive method for predicting post-extubation stridor (PES). However, its accuracy and clinical impact remain uncertain. We aimed to evaluate the reliability of CLT and to assess the impact of pre-extubation variables on the incidence of PES. A prospective observational study was performed on adult critically ill patients who required mechanical ventilation for more than 24 h. Patients were extubated after the successful spontaneous breathing trial, and CLT was conducted before extubation. Of the 191 patients studied, 26 (13.6%) were deemed positive through CLT. PES developed in 19 patients (9.9%) and resulted in a higher reintubation rate (8.1% vs. 52.6%, p < 0.001) and longer intensive care unit stay (8 [4.5-14] vs. 12 [8-30.5] days, p = 0.01) than patients without PES. The incidence of PES and post-extubation outcomes were similar in patients with both positive and negative CLT results. Compared with patients without PES, patients with PES had longer durations of endotracheal intubation and required endotracheal suctioning more frequently during the 24-h period prior to extubation. After adjusting for confounding factors, frequent endotracheal suctioning more than 15 times per day was associated with an adjusted odds ratio of 2.97 (95% confidence interval, 1.01-8.77) for PES. In conclusion, frequent endotracheal suctioning before extubation was a significant PES predictor in critically ill patients. Further investigations of its impact on the incidence of PES and patient outcomes are warranted.
Collapse
Affiliation(s)
- Aiko Tanaka
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yu Horiguchi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryota Higeno
- Division of Pediatrics, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Ryota Sakaguchi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yukiko Koyama
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hironori Ebishima
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Atsuhiro Matsumoto
- Division of Anesthesiology, Osaka General Medical Center, 3-1-56 Bandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Kanaki Sakai
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Daisuke Hiramatsu
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Noriyuki Ohta
- Department of Anesthesiology, Kindai University Faculty of Medicine, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| |
Collapse
|
5
|
Sun X, Chen C, Zhou R, Chen G, Jiang C, Zhu T. Anesthesia and airway management in a patient with acromegaly and tracheal compression caused by a giant retrosternal goiter: a case report. J Int Med Res 2021; 49:300060521999541. [PMID: 33878943 PMCID: PMC8074480 DOI: 10.1177/0300060521999541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
A giant retrosternal goiter can lead to compression of vital organs in the mediastinum with high risk of acute cardiorespiratory decompensation. Additionally, patients with acromegaly are prone to developing severe airway obstruction and ventilation difficulties during anesthetic induction, leading to hypoxia and an increased partial pressure of carbon dioxide. Therefore, more comprehensive airway management strategies are needed. We herein describe a 57-year-old man with acromegaly and severe tracheal obstruction caused by a giant retrosternal goiter. He presented with a 1-week history of progressive dyspnea and was scheduled to undergo right lobe thyroidectomy and retrosternal goiter thyroidectomy. We created a comprehensive emergency plan for a difficult airway, including regional and topical anesthesia for awake endotracheal intubation, sevoflurane inhalation, small doses of midazolam and sufentanil to increase tolerance, self-made extended-length tracheostomy, video laryngoscope-assisted fiber-optic bronchoscopy, extracorporeal membrane oxygenation, and surgical tracheostomy. Importantly, tetracaine was inhaled through an atomizer, and a laryngotracheal topical anesthesia applicator was used to spray the larynx with 1% tetracaine to reduce stimulation during intubation. The giant goiter was successfully removed through the cervical approach. A carefully designed airway management strategy and close communication among a multidisciplinary operation team are the basis of perioperative anesthetic management for these patients.
Collapse
Affiliation(s)
- Xiaohui Sun
- Department of Anesthesiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Chan Chen
- Department of Anesthesiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China.,Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruihao Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chunling Jiang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
6
|
Kuriyama A, Jackson JL, Kamei J. Performance of the cuff leak test in adults in predicting post-extubation airway complications: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:640. [PMID: 33160405 PMCID: PMC7648377 DOI: 10.1186/s13054-020-03358-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022]
Abstract
Background Clinical practice guidelines recommend performing a cuff leak test in mechanically ventilated adults who meet extubation criteria to screen those at high risk for post-extubation stridor. Previous systematic reviews demonstrated excellent specificity of the cuff leak test but disagreed with respect to sensitivity. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the cuff leak test for predicting post-extubation airway complications in intubated adult patients in critical care settings. Methods We searched Medline, EMBASE, Scopus, ISI Web of Science, the Cochrane Library for eligible studies from inception to March 16, 2020, without language restrictions. We included studies that examined the diagnostic accuracy of cuff leak test if post-extubation airway obstruction after extubation or reintubation was explicitly reported as the reference standard. Two authors in duplicate and independently assessed the risk of bias using the Quality Assessment for Diagnostic Accuracy Studies-2 tool. We pooled sensitivities and specificities using generalized linear mixed model approach to bivariate random-effects meta-analysis. Our primary outcomes were post-extubation airway obstruction and reintubation. Results We included 28 studies involving 4493 extubations. Three studies were at low risk for all QUADAS-2 risk of bias domains. The pooled sensitivity and specificity of cuff leak test for post-extubation airway obstruction were 0.62 (95% CI 0.49–0.73; I2 = 81.6%) and 0.87 (95% CI 0.82–0.90; I2 = 97.8%), respectively. The pooled sensitivity and specificity of the cuff leak test for reintubation were 0.66 (95% CI 0.46–0.81; I2 = 48.9%) and 0.88 (95% CI 0.83–0.92; I2 = 87.4%), respectively. Subgroup analyses suggested that the type of cuff leak test and length of intubation might be the cause of statistical heterogeneity of sensitivity and specificity, respectively, for post-extubation airway obstruction. Conclusions The cuff leak test has excellent specificity but moderate sensitivity for post-extubation airway obstruction. The high specificity suggests that clinicians should consider intervening in patients with a positive test, but the low sensitivity suggests that patients still need to be closely monitored post-extubation.
Collapse
Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan.
| | - Jeffrey L Jackson
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Jun Kamei
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 710-8602, Japan
| |
Collapse
|
7
|
Abdelrahman H, Al-Thani H, Al-Sulaiti M, Tabeb A, El-Menyar A. Clinical Presentation and Surgical Treatment of Retrosternal Goiter: A Case Series Study. Qatar Med J 2020; 2020:13. [PMID: 32391249 PMCID: PMC7198470 DOI: 10.5339/qmj.2020.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/01/2019] [Indexed: 11/03/2022] Open
Abstract
Background: The retrosternal goiter (RSG) is a slow-growing mass often benign in nature; thyroidectomy remains the preferred standard curative treatment. This study aimed to explore the local experience of RSG with respect to the clinical presentation, classifications, management, and outcomes. Method: A retrospective chart review was conducted to include all cases diagnosed with RSG and underwent thyroidectomy between January 1998 and December 2013. Results: A total of 1210 patients underwent thyroidectomy; of which 30 (2.5%) patients were diagnosed to have RSG. The commonly reported symptoms were dyspnea (40%), pain and discomfort (30%), dysphagia (26.7%), and hoarseness (20%). Thirteen patients (43.3%) were completely asymptomatic. The fine-needle aspiration cytology was performed in 22 (73.3%) patients, of whom the majority was benign (77.3%). The grading classification showed that grade 1 is the most frequent (73.3%). Total bilateral thyroidectomy was the most prevailing procedure in 57% cases followed by partial thyroidectomy. All patients underwent retrosternal thyroidectomy through a cervical incision except for one case. Postoperative histopathology showed frequent benign multinodular goiter (83.3%), followed by papillary thyroid cancer (10%) and thyroiditis (6.7%). The most common complication after thyroidectomy was tracheomalacia (13.4%), transient hypocalcemia (10%), and hypoparathyroidism (6.7%). There was no intraoperative or perioperative mortality. Conclusion: RSG is a rare entity often presented with pressure symptoms, mostly involving anterior mediastinum and had a challenging surgical procedure. A large multicenter study is needed to include more cases in order to have a consensus on the definition and classification system for such important clinical goiter presentation.
Collapse
Affiliation(s)
| | - Hassan Al-Thani
- Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | | | - Abdelhakem Tabeb
- Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Clinical Research, Trauma & Vascular Surgery Section, Hamad General Hospital (HGH), Doha, Qatar.,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
| |
Collapse
|
8
|
Surgical Treatment of Substernal Goiters Extending to Posterior Mediastinum. Int Surg 2019. [DOI: 10.9738/intsurg-d-17-00100.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim
The purpose of this study was to identify the clinical features of posterior mediastinal goiters and surgical treatment strategies on the basis of our experiences.
Methods
Clinical data of 23 cases of posterior mediastinal goiters in 122 substernal goiters from a total of 4381 thyroidectomies performed in the Division of Thyroid Surgery of the General Surgery Department of Xiangya Hospital, Central South University, China, during a 6-year period (2010–2016) were analyzed.
Results
Posterior mediastinal goiters have a greater prevalence of compression symptoms compared with anterior mediastinal goiters (P < 0.05). Substernal goiters that extend to posterior mediastinum have a higher probability of mass bottom below the aortic arch than those extending to anterior mediastinum (P < 0.05). A total of 20 posterior mediastinal goiters (87.0%) underwent thyroidectomies by cervical approach without additional incision. In 3 of the 23 patients (13.0%), 1 thoracotomy and 2 thoracoscopic approaches were performed for a complete and safe removal. Postoperative complications occurred in 5 of 23 patients (21.7%), including temporary recurrent laryngeal nerve paralysis and transient hypoparathyroidism in our series.
Conclusions
Surgical removal of posterior mediastinal goiters can be performed safely by a single cervical approach in most patients. Thoracoscopic approach proposes a new treatment strategy with feasibility.
Collapse
|
9
|
Lewis K, Culgin S, Jaeschke R, Perri D, Marchildon C, Hassall K, Piraino T, Thabane L, Almubarak Y, Alshahrani MS, Rochwerg B, Baw B, Szczeklik W, Karachi T, Alhazzani W. Cuff Leak Test and Airway Obstruction in Mechanically Ventilated ICU Patients (COMIC): a pilot randomised controlled trial protocol. BMJ Open 2019; 9:e029394. [PMID: 31326936 PMCID: PMC6661599 DOI: 10.1136/bmjopen-2019-029394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Endotracheal intubation and invasive mechanical ventilation are lifesaving interventions that are commonly performed in the intensive care unit (ICU). Laryngeal oedema is a known complication of intubation that may cause airway obstruction in a patient on extubation. To date, the only test available to predict this complication is the cuff leak test (CLT); however, its diagnostic accuracy and utility remains uncertain. Herein, we report the protocol for the CuffLeak and AirwayObstruction in MechanicallyVentilated ICU Patients (COMIC) pilottrial. METHODS AND ANALYSIS This will be a multicentred, pragmatic, pilot randomised controlled trial (RCT). We will enrol 100 mechanically ventilated patients in the ICU who are deemed ready for extubation. We will exclude patients at a high risk of laryngeal oedema. All enrolled patients will have a CLT done before extubation. In the intervention arm, the results of the CLT will be communicated to the bedside physician, and decision to extubate will be left to the treating team. In the control arm, respiratory therapist will not communicate the results of the CLT to the treating physician, and the patient will be extubated regardless of the CLT result. Randomisation will be done in a 1:1 allocation ratio, stratified by size of the endotracheal tube and duration of invasive mechanical ventilation.Although we will examine all clinical outcomes relevant for the future COMIC RCT, the primary outcomes of the COMIC pilottrial will be feasibility outcomes including: consent rate, recruitment rate and protocol adherence. Clinical outcomes include postextubation stridor, reintubation, emergency surgical airway, ICU mortality, in hospital mortality, duration of mechanical ventilation and ICU length of stay in days. ETHICS AND DISSEMINATION The Hamilton Integrated Research Ethics Board, Imam Abdulrahman Bin Faisal University Institutional Review Board and Bioethical Commission of the Jagiellonian University approved this study. The trial results will be disseminated via publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03372707.
Collapse
Affiliation(s)
- Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sarah Culgin
- The Research Institute of St. Joseph’s Healthcare Hamilton, St Joseph’s Healthcare, Hamilton, Ontario, Canada
| | - Roman Jaeschke
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dan Perri
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| | | | | | - Thomas Piraino
- Department of Critical Care, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Lehana Thabane
- The Research Institute of St. Joseph’s Healthcare Hamilton, St Joseph’s Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yousef Almubarak
- Department of Critical Care, Imam Abdulrahman Ben Faisal University, Dammam, Saudi Arabia
| | - Mohammed S Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Ben Faisal University, Dammam, Saudi Arabia
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- St. Joseph’s Healthcare, Hamilton, Ontario, Canada
| |
Collapse
|
10
|
Brinch FA, Døssing H, Nguyen N, Bonnema SJ, Hegedüs L, Godballe C, Sorensen JR. The Impact of Esophageal Compression on Goiter Symptoms before and after Thyroid Surgery. Eur Thyroid J 2019; 8:16-23. [PMID: 30800637 PMCID: PMC6381902 DOI: 10.1159/000493542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/03/2018] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Benign nodular goiter may be associated with swallowing difficulties, but insight into the associated pathophysiology is limited. The aim of this study was to investigate the effect of surgery on the degree of esophageal compression, and its correlation to swallowing difficulties. METHODS Esophageal compression and deviation were evaluated blindly on magnetic resonance imaging (MRI) of the neck, prior to and 6 months after thyroid surgery for symptomatic benign goiter. Goiter symptoms and swallowing difficulties were measured by the Goiter Symptom Scale of the Thyroid-Specific Patient-Reported Outcome (ThyPRO) questionnaire. Cohen's d was used for evaluating effect sizes (ES). RESULTS Sixty-four patients completed the study. Before surgery, median goiter volume was 57 (range 14-642) mL. The smallest cross-sectional area of the esophagus (SCAE) increased from a median of 95 (47-147) to 137 (72-286) mm2 (ES = 1.31, p < 0.001). Median esophagus width increased from 15 (range 10-21) to 17 (range 12-24) mm (ES = 0.94, p < 0.001) after surgery, while no statistically significant change was observed for the sagittal dimension (anterior-to-posterior), thus reflecting an increasingly ellipsoid esophageal shape. Median esophageal deviation decreased moderately after surgery from 4 (0-23) to 3 (0-10) mm (ES = 0.54, p = 0.005). The goiter symptom score improved considerably from (mean ± SD) 40 ± 21 to 10 ± 10 points (ES = 1.5, p < 0.001) after surgery, and the improvements were associated with improvements in SCAE (p = 0.03). CONCLUSIONS In patients with goiter, thyroidectomy leads to substantial improvements in esophageal anatomy, as assessed by MRI, and this correlates with improved swallowing symptoms. This information is valuable in qualifying the dialogue with goiter patients, before deciding on the mode of therapy. Clinicaltrials.gov (NCT03072654).
Collapse
Affiliation(s)
- Filip Alsted Brinch
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Helle Døssing
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Nina Nguyen
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Christian Godballe
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Jesper Roed Sorensen
- Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark
- *Jesper Roed Sorensen, MD, PhD, Department of ORL Head & Neck Surgery and Audiology, Odense University Hospital, J.B. Winsløws vej 4, DK–5000 Odense C (Denmark), E-Mail
| |
Collapse
|
11
|
Sorensen JR, Bonnema SJ, Godballe C, Hegedüs L. The Impact of Goiter and Thyroid Surgery on Goiter Related Esophageal Dysfunction. A Systematic Review. Front Endocrinol (Lausanne) 2018; 9:679. [PMID: 30524374 PMCID: PMC6256339 DOI: 10.3389/fendo.2018.00679] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 10/29/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with goiter referred for thyroidectomy report swallowing difficulties. This might be associated with esophageal compression and deviation as this is present in a significant number of patients. Studies on how goiter and subsequently its treatment affect the esophagus are sparse and point in various directions. Our aim was to investigate, through a systematic review, the impact of goiter and thyroidectomy on esophageal anatomy, esophageal physiology, and subjective swallowing dysfunction. Methods: The search period covered 1 January 1975 to 1 July 2018, using the scientific databases PubMed and EMBASE. Inclusion criteria were adult patients with goiter who were either observed or underwent thyroidectomy. Search terms were variations of the terms for goiter, esophagus, swallowing, and dysphagia. From an initial 3,040 titles, 55 full text evaluations led to the final inclusion of 27 papers. Seventeen papers investigated, prospectively, the impact of thyroidectomy on the esophagus, while five observational and five retrospective studies were also included. Results: Esophageal anatomy impairment: Esophageal deviation occurred in 14% and esophageal compression in 8-27% of goiter patients. The prevalence increased with goiter size and with the extent of substernal extension. The smallest cross-sectional area of the esophagus increased by median 34% after thyroidectomy. Esophageal physiology changes: Goiter patients had increased esophageal transit time, positively correlated with goiter size, but unrelated to esophageal motility disturbances. Decrease in the upper esophageal sphincter pressure occurred early after surgery, and normalized within 6 months. Swallowing related patient-reported outcomes: Evaluated by validated questionnaires, swallowing symptoms worsened in the early period after thyroidectomy, but improved after 6 months, as compared to baseline. Conclusions: Thyroidectomy relieved patients with goiter from dysphagia, within 6 months of surgery probably via increase in the cross-sectional area of the esophagus. Attention to the impact by goiter on the esophagus is needed, and balanced and individualized information about the potential benefits and risks of thyroid surgery is crucial in the management of patients with goiter.
Collapse
Affiliation(s)
- Jesper Roed Sorensen
- Department of ORL–Head and Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Christian Godballe
- Department of ORL–Head and Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| |
Collapse
|
12
|
Doulaptsi M, Karatzanis A, Prokopakis E, Velegrakis S, Loutsidi A, Trachalaki A, Velegrakis G. Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters. Auris Nasus Larynx 2018; 46:246-251. [PMID: 30055961 DOI: 10.1016/j.anl.2018.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 05/24/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Descending goiter has been a focus of controversy in thyroid surgery until nowadays. This study aims to investigate the diagnosis and treatment options of thyroid goiters extending into the mediastinum and the thoracic cavity. METHODS AND MATERIALS A retrospective study was conducted assessing all cases of substernal goiter managed in a tertiary care referral center within 22 years. Demographics, clinical, operative, anatomical, and pathological data of the patients were recorded and analyzed. RESULTS Among 3.028 total thyroidectomies, 212 procedures for substernal goiters were studied. All cases underwent total thyroidectomy. The surgical approach was cervical in all but two cases. A very low rate of complications and zero mortality were noted. Incidence of malignancy on permanent histology was 16%. CONCLUSION Descending goiter constitutes a major indication for thyroid surgery. The overwhelming majority of descending goiters may be managed surgically through a neck incision. In experienced hands good results with low morbidity should be expected. Such cases should be considered as challenging, however, and therefore management in a referral center may be necessary in order to ensure optimal results.
Collapse
Affiliation(s)
- Maria Doulaptsi
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece.
| | - Alexandros Karatzanis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Emmanuel Prokopakis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Stylianos Velegrakis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Alexia Loutsidi
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - Athina Trachalaki
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| | - George Velegrakis
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Crete School of Medicine, Heraklion, Panepistimiou Avenue, 71500, Crete, Greece
| |
Collapse
|
13
|
Tutuncu AC, Erbabacan E, Teksoz S, Ekici B, Koksal G, Altintas F, Kaya G, Ozcan M. The Assessment of Risk Factors for Difficult Intubation in Thyroid Patients. World J Surg 2017; 42:1748-1753. [DOI: 10.1007/s00268-017-4391-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
14
|
Sturgess DJ, Greenland KB, Senthuran S, Ajvadi FA, van Zundert A, Irwin MG. Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review. Anaesthesia 2016; 72:248-261. [PMID: 27804108 DOI: 10.1111/anae.13668] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2016] [Indexed: 12/17/2022]
Abstract
Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.
Collapse
Affiliation(s)
- D J Sturgess
- Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - K B Greenland
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
| | - S Senthuran
- School of Medicine, James Cook University, Townsville, Queensland, Australia
| | - F A Ajvadi
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - A van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
| |
Collapse
|
15
|
Pluijms WA, van Mook WN, Wittekamp BH, Bergmans DC. Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:295. [PMID: 26395175 PMCID: PMC4580147 DOI: 10.1186/s13054-015-1018-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Endotracheal intubation is frequently complicated by laryngeal edema, which may present as postextubation stridor or respiratory difficulty or both. Ultimately, postextubation laryngeal edema may result in respiratory failure with subsequent reintubation. Risk factors for postextubation laryngeal edema include female gender, large tube size, and prolonged intubation. Although patients at low risk for postextubation respiratory insufficiency due to laryngeal edema can be identified by the cuff leak test or laryngeal ultrasound, no reliable test for the identification of high-risk patients is currently available. If applied in a timely manner, intravenous or nebulized corticosteroids can prevent postextubation laryngeal edema; however, the inability to identify high-risk patients prevents the targeted pretreatment of these patients. Therefore, the decision to start corticosteroids should be made on an individual basis and on the basis of the outcome of the cuff leak test and additional risk factors. The preferential treatment of postextubation laryngeal edema consists of intravenous or nebulized corticosteroids combined with nebulized epinephrine, although no data on the optimal treatment algorithm are available. In the presence of respiratory failure, reintubation should be performed without delay. Application of noninvasive ventilation or inhalation of a helium/oxygen mixture is not indicated since it does not improve outcome and increases the delay to intubation.
Collapse
Affiliation(s)
- Wouter A Pluijms
- Department of Anesthesiology, Zuyderland Medical Centre, Henri Dunantstraat 5, Postbus 4446, 6401 CX, Heerlen, The Netherlands.
| | - Walther Nka van Mook
- Department of Intensive Care Medicine, Maastricht University Medical Centre, P. Debyelaan 25, Postbus 5600, 6202, AZ, Maastricht, The Netherlands
| | - Bastiaan Hj Wittekamp
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Heidelberglaan 100, Postbus 85500, 3584, CX, Utrecht, The Netherlands
| | - Dennis Cjj Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Centre, P. Debyelaan 25, Postbus 5600, 6202, AZ, Maastricht, The Netherlands
| |
Collapse
|
16
|
Schnell D, Darmon M, Meziani F. Faut-il abandonner le test de fuite pour le dépistage de la dyspnée laryngée post-extubation ? MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1024-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
17
|
Stevens JL, Constantinides V, Todd J, Meeran K, Christakis I, Tolley NS, Palazzo FF. Do flow volume loops alter surgical management in patients with a goitre? Clin Endocrinol (Oxf) 2014; 81:916-20. [PMID: 24989056 DOI: 10.1111/cen.12539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 04/11/2014] [Accepted: 06/26/2014] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Flow volume loops (FVLs) are considered part of the workup of patients with thyroid enlargement presenting to the endocrinology clinic. They are used to detect upper airway obstruction (UAO) secondary to tracheal compression (TC) from a goitre. Surgical assessment in contrast tends to focus on clinical evaluation supplemented when required by imaging. The aim of this study was to investigate whether FVLs influence the decision to operate in patients with a goitre. METHODS We identified patients with a goitre referred by the department of endocrinology for FVLs between 2006 and 2011. The results of the FVL were collated, and their impact on patient management was assessed. RESULTS Ninety-six patients were referred for FVL. In 38 patients, the indication was specifically to evaluate the effects of a goitre. Of these, 33 were reported as normal. Five FVLs were reported as abnormal (3 suggesting lung pathology and 2 TC). Both patients with TC on FVL presented no CT evidence of TC and underwent surgery due to abnormal cytology. Of the 33 normal FVLs, 7 underwent surgery: 2 for local compression, 4 for abnormal cytology and 1 for Graves' disease. None of the FVLs influenced the decision to operate. CONCLUSION FVLs may detect subradiological TC, but rarely influence management in patients with a goitre. In view of this and the cost of £235 per investigation, FVL should be reserved for goitre patients with suspected primary lung pathology, where the distinction between large and small airway compression is likely to influence management.
Collapse
Affiliation(s)
- J L Stevens
- Department of Endocrine and Thyroid Surgery, Imperial College NHS Trust, Hammersmith Hospital, London, UK
| | | | | | | | | | | | | |
Collapse
|
18
|
Sørensen JR, Hegedüs L, Kruse-Andersen S, Godballe C, Bonnema SJ. The impact of goitre and its treatment on the trachea, airflow, oesophagus and swallowing function. A systematic review. Best Pract Res Clin Endocrinol Metab 2014; 28:481-94. [PMID: 25047200 DOI: 10.1016/j.beem.2014.03.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this systematic review, we investigated the effects of goitre and its treatment on the trachea and the oesophagus. A total of 6355 papers were screened in scientific databases, which disclosed 40 original studies (nine descriptive and 31 interventional). Although most studies are hampered by a number of methodological shortcomings, it is uncontested that goitre affects the trachea as well as the oesophagus in a large proportion of people. This leads to upper airway obstruction, swallowing dysfunction, or both, which may remain undisclosed unless specifically investigated for. Assessment of the tracheal dimensions should be done by magnetic resonance imaging or computed tomography, and detection of upper airway obstruction by flow volume loops, with focus on the inspiratory component. A clinical evaluation of the oesophageal function is difficult to implement and could be replaced by available and validated questionnaires on swallowing. Although radioiodine therapy and thyroidectomy relieve the negative effect of goitre on the trachea and the oesophagus, many issues remain unexplored.
Collapse
Affiliation(s)
| | | | - Søren Kruse-Andersen
- Department of Cardio-thoracic and Vascular Surgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark.
| | | | | |
Collapse
|
19
|
Ojanguren Arranz A, Baena Fustegueras JA, Ros López S, Santamaría Gómez M, Ojanguren Arranz I, Olsina Kissle JJ. Best approach for posterior mediastinal goiter removal: transcervical incision and lateral thoracotomy. Arch Bronconeumol 2013; 50:255-7. [PMID: 24239133 DOI: 10.1016/j.arbres.2013.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/13/2013] [Accepted: 09/16/2013] [Indexed: 11/30/2022]
Abstract
Surgical removal of intrathoracic goiter can be performed by a cervical approach in the majority of patients. Review of literature shows that experienced surgeons need to perform an extracervical approach in 2-3% of cases. In spite of surgical management of substernal goiter is well defined, there is little available information about surgical approach of intrathoracic goiters extending beyond the aortic arch into the posterior mediastinum. We report two cases and propose combination of cervical incision and muscle-sparing lateral thoracotomy for posterior mediastinal goiter removal. In such cases, we do not favour sternotomy as posterior mediastinum is inaccessible due to the presence of heart and great vessels anterior to the thyroidal mass that would lead to perform a perilous blind dissection. Based in our experience, transcervical and thoracotomy approach is indicated for a complete and safe posterior mediastinal goiter removal.
Collapse
Affiliation(s)
- Amaya Ojanguren Arranz
- Departamento de Cirugía General, Unidad de Cirugía Torácica, Hospital Universitari Arnau de Vilanova, Lleida, España.
| | | | - Susana Ros López
- Departamento de Cirugía General, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - Maite Santamaría Gómez
- Departamento de Cirugía General, Hospital Universitari Arnau de Vilanova, Lleida, España
| | | | | |
Collapse
|
20
|
Riffat F, Del Pero MM, Fish B, Jani P. Radiologically predicting when a sternotomy may be required in the management of retrosternal goiters. Ann Otol Rhinol Laryngol 2013; 122:15-9. [PMID: 23472311 DOI: 10.1177/000348941312200104] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Surgery remains the most effective treatment for retrosternal goiters. These commonly present as asymptomatic lesions in elderly patients, but may also cause airway and esophageal compression and, less commonly, may also be malignant. Although the majority of these goiters are amenable to transcervical thyroidectomy, in a minority of patients sternotomy is required. The ability to predict the need for sternotomy before operation would allow for safer surgery and operative counseling, as well as improved logistical efficiency if coordination with thoracic surgeons is required. In this report, we assess the radiologic factors that might be predictive of the need for sternotomy. METHODS We performed a retrospective review of 97 retrosternal goiters for which thyroidectomy was performed within the otolaryngology department at Addenbrooke's Hospital, Cambridge, between 2001 and 2011. There were a total of 80 cervical excisions and 17 cases in which sternotomy was required. A detailed computed tomographic analysis of these 17 cases was undertaken to assess the predictive factors for the requirement of sternotomy. The factors assessed included posterior mediastinal extension, presence of an ectopic nodule, extension below the carina, extension below the aortic arch, a "conical shape" of the goiter, and tracheal compression. These were compared to the same factors in the control group of 80 patients, and Fisher's exact test was used to determine statistical significance. RESULTS The significant predictive factors for sternotomy, were posterior mediastinal extension, extension below the carina, and a "conical" goiter in which the thoracic inlet becomes a ring of constriction (all p < 0.05). CONCLUSIONS Our results suggest that it is possible to predict on the basis of computed tomographic imaging the need for sternotomy in retrosternal goiters.
Collapse
Affiliation(s)
- Faruque Riffat
- Department of Otolaryngology-Head and Neck Surgery, Addenbrooke's Hospital, Cambridge, England
| | | | | | | |
Collapse
|
21
|
Machado NO, Grant CS, Sharma AK, al Sabti HA, Kolidyan SV. Large posterior mediastinal retrosternal goiter managed by a transcervical and lateral thoracotomy approach. Gen Thorac Cardiovasc Surg 2011; 59:507-11. [PMID: 21751115 DOI: 10.1007/s11748-010-0712-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 09/07/2010] [Indexed: 11/30/2022]
Abstract
Most retrosternal goiters are situated in the anterior mediastinal compartment. Posterior mediastinal goiters are uncommon, comprising 10%-15% of all mediastinal goiters. Although most of the anterior mediastinal goiters can be removed by a transcervical approach, posterior mediastinal goiters may require additional extracervical incisions. We report the case of a large posterior mediastinal goiter extending retrotracheally beyond the aortic arch and azygous vein with crossover from the left to the right side. It was excised using a transcervical and right thoracotomy approach. The literature is reviewed to clarify the management of retrosternal goiters with regard to the various approaches, indications for extracervical incisions, and their complications. In conclusion, whereas most retrosternal goiters can be resected through a transcervical approach, those extending beyond the aortic arch into the posterior mediastinum are better dealt with by sternotomy or lateral thoracotomy. The overall number of complications associated with this approach, however, is higher than that seen with the transcervical approach.
Collapse
Affiliation(s)
- Norman Oneil Machado
- Department of Surgery, Sultan Qaboos University Hospital, PO Box 38, Muscat 123, Oman.
| | | | | | | | | |
Collapse
|
22
|
Shin JJ, Grillo HC, Mathisen D, Katlic MR, Zurakowski D, Kamani D, Randolph GW. The surgical management of goiter: Part I. preoperative evaluation. Laryngoscope 2010; 121:60-7. [DOI: 10.1002/lary.21084] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
23
|
Albareda M, Viguera J, Santiveri C, Lozano P, Mestrón A, Bengoa N, Calvet R, Roger A, Pardillo D, Delgado E, Vila L. Upper airway obstruction in patients with endothoracic goiter enlargement: no relationship between flow-volume loops and radiological tests. Eur J Endocrinol 2010; 163:665-9. [PMID: 20688897 DOI: 10.1530/eje-10-0235] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
Collapse
Affiliation(s)
- M Albareda
- Endocrinology and Nutrition Service, Hospital Moisès Broggi, Saint Joan Despi, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Poglio F, Paolasso I, Falcone Y, Grimaldi S, Cocito D. Upper airways obstruction due to retrosternal goiter in a patient with myasthenia gravis. Neurol Sci 2010; 31:407-8. [PMID: 20112125 DOI: 10.1007/s10072-009-0203-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 12/10/2009] [Indexed: 10/19/2022]
|
25
|
Wittekamp BHJ, van Mook WNKA, Tjan DHT, Zwaveling JH, Bergmans DCJJ. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:233. [PMID: 20017891 PMCID: PMC2811912 DOI: 10.1186/cc8142] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Laryngeal edema is a frequent complication of intubation. It often presents shortly after extubation as post-extubation stridor and results from damage to the mucosa of the larynx. Mucosal damage is caused by pressure and ischemia resulting in an inflammatory response. Laryngeal edema may compromise the airway necessitating reintubation. Several studies show that a positive cuff leak test combined with the presence of risk factors can identify patients with increased risk for laryngeal edema. Meta-analyses show that pre-emptive administration of a multiple-dose regimen of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation. If post-extubation edema occurs this may necessitate medical intervention. Parenteral administration of corticosteroids, epinephrine nebulization and inhalation of a helium/oxygen mixture are potentially effective, although this has not been confirmed by randomized controlled trials. The use of non-invasive positive pressure ventilation is not indicated since this will delay reintubation. Reintubation should be considered early after onset of laryngeal edema to adequately secure an airway. Reintubation leads to increased cost, morbidity and mortality.
Collapse
Affiliation(s)
- Bastiaan H J Wittekamp
- Department of Intensive Care, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands.
| | | | | | | | | |
Collapse
|
26
|
Hardy RG, Bliss RD, Lennard TWJ, Balasubramanian SP, Harrison BJ. Management of retrosternal goitres. Ann R Coll Surg Engl 2009; 91:8-11. [PMID: 19126330 DOI: 10.1308/003588409x359196] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- R G Hardy
- Department of Endocrine Surgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK.
| | | | | | | | | |
Collapse
|