Approximately 5% of goitres extend below the thoracic inlet and can potentially become life threatening due to com pression of the airway and major vessels. Approximately 7% of these goitres which require surgical resection will need an additional sternotomy to deliver the intra-thoracic component. Massive retrosternal toxic goitres presenting acutely are rare and are described infrequently in literature. We hereby present two cases of massive retrosternal thyrotoxic goi tres presenting with acute respiratory failure, requiring non-invasive ventilation, as well as significant head and neck venous compression. Surgery on the thyrotoxic patient with a goitre, even if not significantly enlarged, is associated with a high peri-operative mortality due to cardiac instability and hemorrhage. We discuss the challenges of surgical intervention in these patients with particular emphasis on the timing of surgery to relieve compressive symptoms and the time needed to achieve a euthyroid state. We also emphasize the need for meticulous hemostasis, use of a cell-saver, transfusion protocols, adjuncts to hemostasis, as well as careful monitoring and continuous adjustments to the coagula tion profile.
Goitre is a common condition with the definition of an enlargement of thyroid tissue. The accepted definition of retrosternal goitres are extension of greater than 50% of the thyroid tissue into the mediastinum. In 5% there is retrosternal extension, which can become life threatening if there is a rapid enlargement or hemorrhage [
Case one is a 64-year-old female who presented with shortness of breath. She presented in a thyrotoxic state. Her free thyroxine level was 21.2 pmol/L (9.0 - 19.0) and thyroid stimulating hormone (TSH) < 0.01 mU/L (0.4 - 4.9). CXR and subsequent CT scan showed a large mediastinal mass compressing the brachiocephalic vein and trachea (
findings were of a colloid goitre with no evidence of neoplasm.
Case two was also a 64-year-old female who presented with shortness of breath and required BPAP on HDU. She had undergone a partial thyroidectomy 1986 and in 1999 was referred to a cardiothoracic surgeon for further resection. At this stage she declined surgical intervention. On her latest admission a CT scan showed a large multinodular retrosternal goitre (
Multinodular goiters arises from the variable growth of individual nodules. These may follow a path of hemorrhage, degeneration, healing and fibrosis. One of the most common symptoms of compression from retrosternal goitres is dyspnea. Both our patients presented with these symptoms and given the slow growth of the mass and
typical age of these patients these symptoms are often mistaken for diagnoses such as chronic obstructive pulmonary disease or cardiac failure [
Non-surgical treatment by means of radioactive iodine and a thionamide is rarely successful. 1% - 11% of resections require a sternotomy [2,5]. Factors found to increase the need for an extra-cervical approach are malignancy, weight of thyroid tissue and extension to the carina [1,2].
Thyrotoxic goitres have been operated on since their description in the 1830s. These goitres are highly vascular and pose a significant risk of hemorrhage in the perioperative period. High mortality rates did not decrease until the use of pre-operative iodine and subsequently thionamides [
The outcome of our second case could be explained by her increased comorbidities. She presented in extremis and required immediate care in the intensive care setting. This is to stress the gravity of managing massive thyrotoxic goitres.
Our recommendations are that these retrosternal goitres should be removed early due to the risk of compressive symptoms. Chest radiographs are a good first line investigation and CT should follow thereafter. Sternotomy should be considered in cases where there are suggestions of malignancy or a large thyroid volume. Hemorrhage should be anticipated and adequate preparations made. This should be by the means of administering thionamides as early as possible, the use of intra-operative cell salvage, monitoring coagulation during and after the procedure by the use of thromboelastography (TEG® or ROTEM®) and correction with blood products and clotting factors.