Pubmed comprises more than 26 million citations for biomedical literature from medline, life science journals, and online books. Jul 01, 2000 rowbotham combined local analgesia with light general anaesthesia and even contrived, at the request of the surgeon, to get the patient to strain when the haemostatic sutures were in place. It remains unclear which goitres are to be termed substernal, but a recently proposed definition is a goiter that requires mediastinal exploration and dissection for complete removal or an intrathoracic component extending more than 3 cm in the thoracic inlet 1. While most of these retrosternal goitres can be excised through a standard cervical collar incision, 412% of patients will require an additional thoracic incision such as a manubriotomy, sternotomy, thoracotomy or mediastinotomy. Functionally, most cases are euthyroid, but they can present with either hyper or hypothyroidism. Anesthetic management of a patient with retrosternal. We present the anesthetic management in a patient with a large goiter with retrosternal extension leading to tracheal compression and.
Difficult airway challengesintubation and extubation. Video assisted thoracoscopic thyroidectomy for retrosternal. Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. The retrosternal substernal goiter majeed h alwan 21 bas j surg, 16, march, 2010 different from that incidence of totally cervical nodular goitre. If this goal of surgery can be met, while limiting surgery to removal of a single. Although the great majority of retrosternal goitres are extensions from the neck, pure intrathoracic goitres do occur. Case presentation a 83yearold woman with retrosternal goiter was referred to a tertiary hospital for left hemithyroidectomy after being rejected in the anaesthesia department of a secondary care centre because of. Majority of retrosternal thyroid can be removed safely by. Patients should have a full head and neck examination with particular focus on the presence. Anaesthesia for obstructive symptomatic retrosternal. The most commonly recognised and appropriate term is intrathoracic goitre. The prevalence of goiter as a single risk factor was 6. Quadbeck b, pruellage j, roggenbuck u, hirche h, janssen oe, mann k etal. In endemic goiter areas, 20% of the population over the age of 70 will have a retrosternal goiter.
The use of remifentanil for thyroid surgery has become increasingly popular. Chest xray of retrosternal goitre showing marked deviation of the trachea windpipe to left a retrosternal or substernal goitre occurs when the thyroid grows downwards from the neck into the chest. A goiter often causes a noticeable swelling in the neck. If retrosternal goitre is huge then another awake technique is to establish cardiopulmonary bypass cpb or extracorporeal membrane oxygenation ecmo via femoral vessel cannulation under local anaesthesia, although this is only available in specialist hospitals. When this occurs, thyroidectomy surgery excision of part or all of the thyroid gland has unique considerations that are important to understand for the surgeon and patient. Should asymptomatic retrosternal goitre be left untreated. However, the incidence of cancer in patients with ssg is reported in several studies to be between 2. Anaesthesia for thyroid surgery anaesthesia tutorial of the week 162 30th november 2009 lucy adams, specialty registrar. A goiter is an enlarged thyroid gland, which is a butterflyshaped gland in the front of the neck. Thyroidectomy using monitored local or conventional general anesthesia. Anesthetic management of a patient with retrosternal goiter using.
Substernal goiter is a goiter enlarged thyroid gland with intrathoracic extension. Any goiter that descends below the plane of the thoracic inlet or grows into the anterior mediastinum for 2 cm is considered retrosternal. Anesthesia for massive retrosternal goiter with severe intrathoracic. Anaesthesia for massive retrosternal thyroidectomy in a. Difficult airway challengesintubation and extubation matters. They are rare, representing less than 1% of all rgs secondary rgs develop from the thyroid. Regional anaesthesia for thyroid surgery is seldom used in the uk but has been.
Thyroidectomy for retrosternal goiters should be performed by. Atotw 162 anaesthesia for thyroid surgery, date 30112009. They are rare, representing less than 1% of all rgs. A goiter can be caused by a lack of iodine in the diet, a tumor or nodule on the gland, a thyroid disease, or, in rare cases, cancer. Anesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing. Enlarged thyroid glands ie, goiters often extend in the mediastinum posterior to the sternum, making the gland, by definition, a substernal or retrosternal goiter. Retrosternal goiter arises from lower pole of thyroid gland usually symptomless diagnosed by cxr ss dysponea,dysphagia, cough, engorged neck veins, stridor, recurrent laryngeal nerve palsy cxr soft tissue shadow in the superior medistinum deviation and compression of trachea. The generally accepted definition is that described by candela in 2007. Surgeons with multidisciplinary team involvement, the proper diagnosis is ascertained. A retrosternal thyroid refers to the abnormal location of all or part of the thyroid gland below the breastbone sternum. Retrosternal goitre rsg may be classified depending on the location of the goitre.
Airway management of a huge thyroid swelling with retrosternal extension by awake intubation using locosedative technique garima g ladha, nidhi d patel, neeta kavishvar department of anesthesiology, government medical college, new civil hospital, surat, gujarat, india. He used one breath of ether to accomplish this manoeuvre. Surgical intervention is the treatment of choice for substernal goiter. Department of anesthesiology, government medical college, new. We describe a 57 year old lady with massive retrosternal goiter and severe intrathoracic tracheal compression who had a total thyroidectomy. A retrosternal goiter is always a consideration in people who have a mass sticking out of the neck.
Dec 11, 2015 surgical intervention is the treatment of choice for substernal goiter. A careful preoperative evaluation of the thoracic structures involved and stepwise induction of anesthesia, with standby cardiopulmonary bypass, are essential. During a 22year period, we treated 44 patients with intrathoracic multinodular goiter. Anaesthesia for thyroid and parathyroid surgery bja. Lippincott journals subscribers, use your username or email along with your password to log in.
Radiological examination including chest xray and magnetic resonance imaging mri revealed diffusely enlarged thyroid gland with left lobe measuring 11. Thyroidectomy is advocated for patients with retrosternal goitre. 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 1. Goitre definition of goitre by the free dictionary. Thyroidectomy for massive goiter weighing more than 500. We would like to report a case of massive goiter encasing major neck structures and how it was managed. Previous reports of thyroidectomy under local anaesthesia were not for giant goiters. Anaesthesia for massive retrosternal thyroidectomy in a tertiary.
A diagnostic and treatment dilemma gamal khairy, abdulaziz alsaif. Many terms are used to describe the entry of the thyroid gland into the thoracic cavity include. Retrosternal goiter is a common cause of compression of adjacent structures, and it may harbor cancer. The myth of tracheomalacia and difficult intubation in cases. The myth of tracheomalacia and difficult intubation in. Anaesthetic management of retrosternal goitre request pdf. Anaesthetic management of acute airway obstruction singapore. One hundred ninetynine patients presented for thyroidectomy.
A relatively common upper tracheal lesion is the goitre. An acute thyroid crisis at induction of anaesthesia, which was mistakenly diagnosed as malignant hyperthermia, was successfully treated by boluses of dantrolene 1 mg kg. Supportive management includes hydration, cooling, inotropes and formerly steroids. Massive goiter with retrosternal extension may impose additional risk such as difficult intubation, tracheomalacia, and possibility of different incision and approach including sternotomy. The study was performed in a tertiary centre with a. A retrosternal goitre occurs when the thyroid enlarges downwards into the chest. Retrosternal extension of goiters is not uncommonin iodinedeficient areas it has been reported to occur in as many as 25% when screening persons over 70 years of age with no evident thyroid disease. There is controversy over whether patients with asymptomatic retrosternal goiter should be operated.
This case delineates the need for a multidisciplinary approach and possible challenges in anaesthesiology. Riehl j, kierdorf h, schmitt h, suiter t, sieberth hg. Thyroidectomy, massive goiters, tracheomalacia, retrosternal goiter. Very rarely a left sided cervical goitre descends into the right side of the chest this is. The latter group include dyspnoea, dysphagia, and features of superior vena cava svc obstruction and nerve compression horners syndrome, and recur. Literature regarding airway management in obstructive retrosternal goiter is limited to case reports, case series and retrospective studies. It is estimated that nodular goiter affects 5% of the general population 1. Ultrasound volumetry of the thyroid gland of 1,336 adults in an endemic goiter region. Retrosternal goitre is very rare condition which account for 5 to 20% of thyroidectomy patients. The thyroid gland is normally located at the front of the neck.
The usual goiter growth ratio is estimated at 10 to 20% per year, though high individual variability in the clinical course makes it difficult to predict. Two cases of early postoperative tracheomalacia were reported, one in the retrosternal group. Accordingly, all surgeons treating thyroid disorders will be faced with the particular problems associated with retrosternal goiter, both preoperatively when deciding. Proponents argue that retrosternal goiter may be a risk for thyroid cancer and may progress to later cause symptoms, although clear evidence is missing. Nov 08, 2014 thyroidectomy is advocated for patients with retrosternal goitre. Signs of tracheal compression and vocal cords palsy examination of goiter should include the size, consistency, duration and extent of enlargement. It is often detected when a chest xray or ct scan is done for another reason. Retrosternal goitres are more likely to be left sided. Massive goiter with retrosternal extension encasing. Citations may include links to fulltext content from pubmed central and publisher web sites. Multidisciplinary management of airway obstruction and. Difficult airway challengesintubation and extubation matters in a.
It has a clinical importance because its compressive symptoms may. In this article we report a rare case of 55 year old female who had nodular goiter with huge retrosternal extension associated with hyperthyroidism. Anesthetic management of a patient with retrosternal goiter. Goiter healthcare baylor college of medicine houston, texas. Retrosternal goiter of the thyroid gland is the inclusion of 50% or more into the thoracic cavity. Clinical practice anaesthesia for massive retrosternal thyroidectomy. Yet, surgery for retrosternal goiter is associated with more complications than cervical goiter. Goiter healthcare baylor college of medicine houston. A useful investigation when a retrosternal goitre causes symptomatic tracheal compression.
Primary intrathoracic goitres arise from aberrant thyroid tissue which is ectopically located in the mediastinum, receive their blood supply from mediastinal vessels and are not connected to the cervical thyroid. Seorang penderita dengan retrosternal goiter mawardi. Huge nodular goitre with retrosternal extension a rare. While there are numerous reports in the literature concerning the surgical management of rsg 15 and ensuing problems 68 those considering anaesthetic management are frequently limited to. Specific concerns include problems with tracheal intubation, mechanical ventilation, or postoperative tracheomalacia, but opinion on the optimal anaesthetic management is divided. Patients with a massive retrosternal goitre mrsg may present difficulties with airway management. A retrosternal goiter often causes no symptoms for years. Airway management of a huge thyroid swelling with retrosternal. Request pdf anaesthetic management of retrosternal goitre a 55 years old female having a multinodular goitre with retrosternal extension and tracheal compression was posted for total. Anaesthesia for thyroid surgery, date 30112009 page 1 of 9. Detection of a tracheal obstruction caused by a retrosternal.
Of 4572 patients in the database, 919 20% had a retrosternal goitre. This type of goiter is associated with tracheal and esophageal compression and during surgery may result in injury to the recurrent laryngeal nerve and vocal fold paralysis. Betablockade by labetalol or esmolol and antithyroid drugs is the firstline treatment. Anesthetic management in thyroid disorder authorstream. The incidence of retrosternal goiter varies from 3 to 20 per cent with respect to thyroidectomy patients. Fixed and hardness of the gland points toward malignancy, while inability to feel the lower border of thyroid gland indicates retrosternal extension. Anaesthesia for obstructive symptomatic retrosternal goiter. May 24, 2012 anesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing. Retrosternal, substernal and intrathoracic goitre is a subgroup of multinodular goitre mng. Anaesthesia may be maintained via inhalation agents or i. Preoperative considerations history taking and assessment focuses on the patients thyroid status, predictors of difficult airway, and symptoms and signs secondary to the goitre. In an additional 122 patients, goiter was discovered as a random preoperative finding, a prevalence of 2.
Retrosternal or substernal goitres are extensions of a thyroid goiter behind the manubrium sterni. Background airway management in large and retrosternal goiters with tracheal compression is often fraught with challenges and is a source of apprehension among anesthesiologists globally. Difficult airway challengesintubation and extubation matters in a case of large goiter with retrosternal extension chetankumar b raval, syed abdul rahman department of anesthesiology, icu and perioperative medicine, hamad medical corporation, doha, qatar. Retrosternal goitre is usually referred to as enlarged thyroid gland. Giant goiter is an enlargement of the thyroid gland not less than 10gmkilogram body weight. Remifentanil provides analgesia intraoperatively, and also contributes to the hypotensive anaesthetic required to provide a bloodless surgical field.
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