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Intrathoracic goiter
INTRATHORACIC HOWARD M.
T
GOITER
CLUTE, M.D. AND KNOWLES B. LAWRENCE, M.D. BOSTON, MASSACHUSETTS
HE fact that certain goiters are partIy or whoIIy intrathoracic is now accepted as a serious and not uncommon pathoIogic condition. When one considers that many of these goiters are compIeteIy hidden in the bony thorax, however, it is not surprising that onIy in recent medica times has much been known of this disease. Intrathoracic goiter was first described anatomicaIIy by A. HaIIer in I 749. l It was much later, in 1830, when C. Ling12 gave the first cIinica1 description of this Iesion. in 1826, recorded an M. Dubourg,3 instance of stranguIation and death due to intrathoracic goiter, and in 1828 A. AdeIman4 reported a case of malignant disease in this type of goiter. The term, “goiter pIongeant,” was coined by MaIard in 185 15 to appIy to those substerna adenomas which popped up into view above the sternum with increased intrathoracic pressure. The monograph, “Die Struma Intrathoracica,” by F. Wuehrman, in r8g66 was the most comprehensive study to that date. The recognition of intrathoracic goiter in the earIier years was, of course, Iimited by the Iack of roentgen diagnosis unti1 1899. At this time Schieff’ added another most important miIestone to the understanding of this disease by showing the vaIue of the x-ray in the diagnosis of intrathoracic goiter. It is interesting today to note that the cIassica1 descriptions of exophthaImic goiter by Parry, Graves, and Basedow, as quoted by Major,8 faiIed to include any case in which the symptoms and signs were those of a goiter extending into the thorax beIow the sternum. This finding is in accord with present day experience that the thyroid gIand in typica exophthaImic goiter rareIy, if ever, extends deeply into the thorax. One cannot but wonder if these writers saw no cases of hyperthyroidism due to a sub-
sterna1 adenomatous goiter which were diffrcuIt of expIanation. ConsiderabIe confusion has existed in descriptions of intrathoracic goiter because of different nomencIatures used by various authors. IncIusion of the terms, “substerna1 ” and “ retrosterna1” and “subcIavicuIar,” under the singIe grouping of “intrathoracic” goiter seems ampIy justified and has been fairIy we11 accepted. From 12 to 30 per cent of a11 goiters couId be so classified according to various reports.1,4,svg Some authors, however, prefer to Iimit the term, “intrathoracic,” to those goiters which extend down to or beIow the arch of the aorta. If this more rigid definition is foIIowed, incidence of intrathoracic goiter ranges from Iess than I to IO per cent of a11 goiters operated upon.10~11,12 Intrathoracic goiter arising from ectopic thyroid tissue deep within the mediastinum is quite rare. The case of Means” in which the mass rested on the diaphragm may faI1 into this category. From embryoIogic considerations such grands shouId Iie in cIose reIationship to the aortic arch or possibIy the trachea1 bifurcation. They may or may not be connected with the thyroid proper by a fibrous cord.’ Ptosis of the norma thyroid gIand, or a sIight dipping down of cervica1 goiter behind sternum or cIavicIes shouId not be cIassified as intrathoracic goiter, since onIy part of such goiters are at best subcIavicuIar. Intrathoracic goiters deveIop when a single adenoma or one or more of the noduIes of a muItipIe adenomatous goiter descend through the superior thoracic strait into the bony thorax, Most frequently intrathoracic goiters arise from adenomatous goiters, but occasionaIIy a single discrete adenoma which once Iay in the Iower poIe of one thyroid Iobe wiI1
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descend into the thorax. The descent of these singIe or multipIe noduIes into the thorax depends first on their Iocation in the gIand. ObviousIy, a discrete noduIe Iocated in the superior poIe of the thyroid gIand wouId not find its way into the chest. When, however, the noduJe is present in the Iower portion of either of the thyroid Iobes or of the thyroid isthmus, it may, as it grows in size, readiIy descend through the superior thoracic strait. One of the factors that influences this descent is the rate of growth which usuaJIy is so sIow that it requires years for the goiter to enter the thorax. It is, of course, occasionaIIy true that a Iow-Iying discrete adenoma in a young person wil1 have a hemorrhage into it, and since the Ieast resistance to its expansion is in the downward direction, it wiII so descend into the chest. Whether the growth of these adenomas of the thyroid is rapid or sIow, there is nothing but Ioose ceIIuJar tissue to restrict their descent into the thorax through the superior strait. Expansion in other directions is Iimited by muscIes, vesseIs or bone. The fascia, descent of these Iow-Iying adenomas is furthermore aided very markedIy by the contractions of the sternomastoid muscIes and of the prethyroid muscles that accompany motions of the head and acts of respiration and degIutition and to some degree by the force of gravity itseIf. ANATOMY
The anatomica relation of intrathoracic goiters is most important, not 0nIy in considering the effects of these thoracic masses upon adjacent structures but also in the surgica1 management of their removal It must be recognized that all, or practicahy aI1, intrathoracic goiters Iie in the cIosest association to the trachea, and this reIationship to the treachea is one of the important factors in their diagnosis and in their surgica1 management. It is perfectIy obvious, when one considers the origin of the intrathoracic masses from an adenomatous enIargement of the thyroid gIand surroundthat the intrathoracic ing the trachea,
portion of the goiter may Iie either to the right, to the Ieft, in front of, or behind the trachea. Furthermore, in some cases the adenomatous mass may entireIv encircIe the trachea with extensions running backward from each Iobe. Most commonIy, intrathoracic goiters extend from the Iower pore of either the right Iobe or the Ieft Jobe of the thyroid directly down aIong the trachea into the superior mediastinum. Less common, in fact quite unusual, is the type in which adenomatous noduIes grow backward between the branches of the inferior thyroid artery and then go downward behind the trachea. This type is occasionaIIy overIooked in goiter operations because the intrathoracic portion Iies out of sight behind the thyroid Iobe in the neck. The arteria1 suppIy to intrathoracic goiters comes from the same arteries that suppIy the norma thyroid gIand. Both the superior and inferior thyroid artery have considerabIe sIackness due to their winding course from the major arteria1 trunk to the thyroid gIand. This is most important, not onIy because it permits portions of the thyroid gIand to descend with their arteria1 suppIy intact but also because it permits contro1 of the bIood suppIy of intrathoracic goiters by controIIing the major thyroid arteries in the neck. The superior thyroid artery, after it Ieaves the externa1 carotid artery, goes up the neck somewhat and then curves downward to join the superior thyroid poIe. The inferior thyroid artery, after it Ieaves the thyroid axis of the subcIavian artery, goes up the neck in quite a wide arch, and after passing beneath the carotid artery and the juguIar vein at a IeveI just below the superior thyroid poIe, descends aIong the gIand and enters it in the Iower or middle portion of the Iobe. It is apparent from this distribution of these two major arteries that if structura1 changes in the thyroid gIand occur, and the lobe or part of the Iobe descends into the chest, there is sufficient laxity in these arteries to permit them to descend with the Iobe. Certainly there is nothing in their
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anatomical arrangement which at the start of the descent of the goiter into the thorax exerts tension to hinder this process. The veins coming from the thyroid gJand empty in Jarge part into the interna juguJar vein, and it seems to be possibJe for these veins aJso to eJongate as part of the thyroid Jobe descends into the thorax. AJmost never have we had any significant Venus bJeeding from within the thorax when a discrete adnomatous mass was Jifted out of the chest. The veins a11 come up with the mass and Jead into the juguJar vein at a JeveJ which usuaJIy is readiJy seen in the operative wound in the neck. These anatomica arrangements of the arteries and veins are most important, then, in the surgica1 remova1 of intrathoracic goiters. The effect that the descent of thyroid adenomas into the thorax has upon the recurrent JaryngeaJ nerve wiJ1 vary, of course, with the Jocation of the thyroid mass before it starts downward into the chest. It is, nevertheJess, true that in most instances, in spite of the presence of deep intrathoracic goiters, there is no voca1 cord paraJysis. In the past it has been said that when voca1 cord paraJysis was present one couJd be quite certain that maJignant degeneration of the intrathoracic mass had occurred. This, however, we now know to be a mistake, because we have severa times seen preoperative paraJysis of one cord in the presence of Jarge substernal goiters in which there was no evidence of maJignancy. Whether the substerna goiter pushes the recurrent JarvngeaJ nerve backward as it descends, or in occasiona cases in which the goiter descends between branches of the inferior thyroid artery, presses it forward, wiJJ of course depend on the point of origin of the goiter. It is our experience, however, that in most cases the recurrent nerve is pushed backward and is we11 out of the way of the surgeon at the time of the operation. PATHOLOGY
Most intrathoracic goiters, as we have said, arise from a muJtipJe adenomatous
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goiter, or the so-caJJed noduJar goiter. Less often they resuJt from the descent into the thorax of a singJe discrete adenoma. Whichever of these two basic pathoJogica1 factors is present, the intrathoracic goiter is subject to the same degenerative changes that may occur in a goiter which is entireJy cervica1 in location. Hyperplasia of the intrathoracic thyroid tissue can occur, and in fact, not infrequentJy does. This resuJts in the deveJopment of toxic symptoms, and we have a cIinica1 picture here very JittJe different from that seen in toxic adenomatous goiter when it is in the usua1 position in the neck. Degenerative changes may occur in the substerna mass with necrosis, hemorrhage and cyst formation. OccasionaJJy, such cysts become very Jarge and produce very serious pressure symptoms. CaJcification in varying degree may occur in the intrathoracic goiter, presumabJy because intrathoracic goiters are goiters which have been present for many years. In some cases maJignant degeneration occurs just as it does in noduJar goiter in the neck. The maJignancy may be diffuse, invading a11 the structures and going outside of the thyroid capsuJe, or it may be JocaJized within a discrete adenoma. It may be of any of the types that one sees in thyroid pathoJogy in the neck. PHYSIOLOGY
Changes in the physioJogy due to the presence of an intrathoracic goiter are reJated first to the possibiJity that hyperthyroidism has deveJoped because of hyperpIasia in the intrathoracic mass. This hyperthyroidism is in no way different, in our experience, from the hyperthyroidism that comes from noduIar goiter in peopIe of middIe Jife and beyond. Its presence, of course, adds distinctJy to the risk of remova1 of the intrathoracic goiter, just as the presence of hyperthyroidism adds appreciabJy to the remova of any Iarge goiter. The changes in the physioJogy which are specificaJJy reJated to the anatomical posi-
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tion of the goiter in the thorax are a11 changes which are due to the presence of an intrathoracic mass, and depend on the
rowed that the patient has a constant stridor on inhaIation. In certain instances the patient finds that there are certain
pressure of this mass on the surrounding structures. The trachea is the earliest organ to show the effect of this pressure. It is deviated from its midIine position by the presence of the substerna mass. If the substerna mass Iies on both the right and the Ieft side of the trachea, then it is, of course, narrowed by this biIatera1 pressure. If the goiter Iies behind the trachea, the trachea may be broadened IateraIIy and at the same time its Iumen narrowed anteroposteriorIy by the enIarging goiter forcing it against the sternum. A simiIar condition may arise when the goiter Iies in front of the trachea and pushes the trachea backward toward the spine. The degree of tracheal pressure wiI1, of course, depend on the size of the substerna goiter and the amount of trachea1 deviation present. In some cases the trachea becomes so nar-
positions of the head in which pressure on the trachea is very much increased and he consciousIy avoids these positions. Thus we have patients who cannot sIeep with their head bent sharpIy forward because this obstructs their breathing. Others cannot lie on one side or the other in bed because again the trachea is bent over the substerna1 mass and is definiteIy narrowed by this mechanica change in its position. It is interesting to observe that very rareIy does a substerna goiter affect the course of the esophagus. PhysioIogicaI effects from the presence of an intrathoracic mass rareIy make any changes on the recurrent IaryngeaI nerve or other nerves in the neck. In a few instances, however, uniIatera1 vocal cord paraIysis has occurred in our experience probabIy due to stretching of the recurrent
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IaryngeaI nerve. The presence of this paraIysis in the recurrent nerve may not be recognized by the patient and wiII be found
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individuaIs that puffiness of the face and duskiness of coIor are distinctIy noticeabIe and very Iarge diIated veins are pIainIy
FIG. 2. (M. R.) An obIiqueIy Iateral x-ray in this case demonstrates deviation of the trachea backward with compression by an intrathoracic goiter at Ievel of the manubrium sterni. At one point the trachea is narrowed to one-third normal diameter. The size of the soft tissue mass is clearly shown.
onIy by routine examination of the voca1 cords. In other instances, however, goiter patients consuIt the physician because of the fact that they have recentIy deveIoped hoarseness and this may be the first symptom of a substerna goiter. In patients who have very Iarge intrathoracic goiters, there is sufficient pressure of the goiter against the venous structures coming down through the superior thoracic strait to produce definite engorgement of the veins in the neck and over the chest waI1. Such venous engorgement is very marked in certain Iarge goiters, and yet, curiousIy enough, in other deep intrathoracic thyroid tumors there wiII be IittIe or no venous engorgement. The venous engorgement may be so marked in some
visibIe over chest waI1.
the
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DIAGNOSIS
The diagnosis of intrathoracic goiter can be made, not infrequentIy, from carefu1 consideration of the patient’s history, but in many instances it is made onIy by cIinica1 and x-ray examination. The cIinica1 symptoms that are suggestive of intrathoracic goiter are varied, but most of them are the resuIt of pressure of the intrathoracic mass on the trachea, on veins or on the recurrent IaryngeaI nerve. OccasionaIIy, a patient is seen who says that she had a goiter many years ago, but that it “disappeared.” When a definite sizeabIe mass in the area of the thyroid
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FIG. 3. (M. C.) In the anteroposterior x-ray (a) of this patient, the trachea is bareIy visuaIized, but ently nearIy in the midline. A soft tissue mass is shown extending below the aortic arch, particuIarIy right. A lateral film (b) demonstrates marked anterior deviation of the trachea with narrowing of its Barium swaIIow (c) indicates that the goiter Iies behind the esophagus also, this structure being forward with the trachea.
apparon the Iumen. pushed
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“disappears,” one may be very suspicious that it has descended through the superior thoracic strait and so passed from view.
a
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hoarseness, and not infrequently the discovery of paralysis of one voca1 cord by a physician, Jeads to the search for a possibIe
b
(A. F.) Deviation of the trachea backward and to the right by the pressure of an intrathoracic goiter are shown (a) in the Iateral and (b) anteroDosterior x-rays. These are the usual views taken in x-ray diagnosis of intrathoracic goiter.
FIG.
4.
More commonIy the patient’s history states that there has been an increasing sense of pressure in the throat. OccasionaIIy, this pressure takes the form of a Iump in the throat which is noticeable when solid foods are swallowed. In we11 deveIoped intrathoracic goiters the patient notices very definiteIy the stridor and difficuIty of breathing that accompany narrowing of the trachea. When the intrathoracic mass lies on one side of the trachea and pushes the trachea we11 away from the midIine, the patient wiII not infrequentIy state that when she Iies with her head on the side at which the goiter is, she has obstruction in breathing; and when she Iies with her head on the' side away from the goiter, there is less troubIe in breathing. The mechanics of this arrangement are perfectIy IogicaI and readiIy understandable. In some patients the deveIopment of
substerna goiter. In other instances the gradua1 deveIopment over a period of years of increasingIy Iarge veins at the base of the neck and over the upper chest, Iikewise show the possible presence of substerna goiter. In some individuaIs the deveIopment of hyperthyroidism, in the absence of any apparent goiter in the neck, may Iead the physician to search for a substerna goiter. The presence of rea1 hyperthyroidism with no paIpabIe enIargement of the thyroid gIand in the neck shouId make any physician consider the possibility of an adenomatous goiter beneath the sternum in the mediastinum. The physical signs that accompany the presence of substerna goiter are varied. In the norma individua1 one can, with considerabIe practice, paIpate the upper poIe and the Iower poIe of both the right and Ieft Iobes of the thyroid. If the thyroid is
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enIarged, this paIpation of the poIes is much simpIer. If then, in the presence of an adenomatous goiter, one can fee1 the superior poIe on each Iobe, and the inferior poIe on one side, but is quite unabIe to get beneath the inferior poIe and feel its Iower borders on the other side, he at once becomes suspicious, if not certain, that there is a substerna extension and an intrathoracic goiter. In some patients there is a discrete adenoma beneath the sternum which rises in the neck when the patient coughs or sneezes or in any other way increases the intrathoracic pressure. This abiIity of a discrete adenoma in the superior mediastinum to rise up into the neck is not commonIy seen but when present is diagnostic. Intrathoracic goiters, when one can paIpate their superior borders or watch them with the fluoroscope, move up and down with deglutition just as do goiters in the neck. This movement with degIutition helps to differentiate the intrathoracic goiter from intrathoracic dermoids or other tumors. We have never found percussion of the superior mediastinum and increase in the duIIness of this area of great heIp to us in the diagnosis of substerna goiter. Most substerna goiters show, in some degree at Ieast, in the neck, or can be paIpated in the sterna1 notch or just to one side beneath the sternomastoid. When such a mass is feIt and when it rises with degIutition, percussion may heIp the examiner in deciding that there is a Iarger mass beneath the sternum. The diagnosis of substerna goiter can aImost invariabIy be made by satisfactory and adequate x-rays of the superior mediastinum. The x-ray technician must understand that his pictures must be su&ientIy soft to show the outline of the trachea, and the patient must have the trachea fiIIed with air and hoId his breath whiIe the picture is taken. It is very important that not onIy anteroposterior views of the trachea and the superior mediastinum are taken, but aIso that IateraI views as we11 are obtained.
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A discrete adenoma Iying just beneath the manubrium of the sternum and directIy on the trachea may make no great impression on the anteroposterior picture of the trachea, and certainIy the trachea wiI1 not be deviated either to the right or the Ieft of the midIine. However, a IateraI view of the trachea in this same case wiI1 show its marked deviation posterioraIIy, due to the presence of this goiter in front of it. A simiIar situation is obtained when the goiter is behind the trachea and pushes the trachea forward rather than IateraIIy. In some instances x-rays are taken whiIe the patient is swaIIowing a barium mixture, in order to show the reIation of the esophagus to the trachea and to the goiter. This has been very heIpfu1 to show the position of the intrathoracic mass. In many cases of intrathoracic goiter, the goiter itseIf wiI1 not show in the x-ray and its presence wiI1 be known onIy because of its deviation from the norma position in the midIine of the trachea. In other cases, however, when the goiter is very Iarge or when it contains much caIcified material, the actual shadow of the goiter itseIf wiI1 be visibIe; and as x-ray technicians become more expert in their trachea1 pictures, the actua1 shadow of the goiter is more IikeIy to appear in the pIates. TREATMENT
The treatment of intrathoracic goiter is surgica1 remova1, and it is unnecessary to state that the earIier in the course of deveIopment of a substerna goiter surgery is undertaken, the easier, simpIer and safer is the surgica1 procedure. It has been surprising to us to note in many instances the size of intrathoracic goiters that can be removed through the superior thoracic straits without cutting the sternum or freeing the sternocIavicuIar articuIation. In fact, the senior writer in his entire experience has never had occasion to enIarge the bony thoracic strait for the remova of a substerna goiter, nor has he yet encountered such a Iarge noncancerous intrathoracic goiter that it couId not be re-
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moved without enIarging the bony thoracic straits. The anesthesia for the remova of intrathoracic goiters is, of course, of the utmost importance. Here particuIarIy is it necessary to have an anesthetist trained in goiter surgery, and adept in handIing the specific probIems that arise when a trachea is distorted in position and narrowed in its caIiber. We now prefer, and routineIy use, intratrachea1 anesthesia with cycIopropane and oxygen for anesthetic agents. This is the most satisfactory arrangement in our experience. The onIy objection to it, and it is not a serious one, is that the intratrachea1 catheter is somewhat stiff and somewhat resistant when one is attempting to disIocate the intrathoracic mass; and it does not bend and give as much as the trachea wouId if the catheter were not inside of it. However, the fact that anoxemia cannot occur and that the patient’s respiratory process is under the contro1 of the anesthetist, far outbaIances the sIight mechanica1 objection to the catheter in the trachea. The first requirement in the surgica1 remova of an intrathoracic goiter is a wide incision. The usua1 transverse cervica1 incision is made above the cIavicIe, the skin ffap Iifted and the muscIes split in the midIine IongitudinaIIy. The sternomastoid is then freed from the prethyroid muscIes on each side, and the prethyroid muscIes are cIamped and cut on each side, even though the substerna goiter is present on onIy one side. This cutting of the muscIes on the uninvoIved side is not necessary in smaI1 tumors, but in Iarge growths it is very heIpfu1, because it gives a great dea1 of freedom for the Iobe of the thyroid on that side to move when the manipuIations for the extirpation of the goiter in the chest are going on. When the fieId is thoroughIy exposed by wide cutting of the prethyroid muscIes and thoroughIy dry, a carefuI expIoratory finger is pIaced aIong the posterior surface of the capsuIe covering the intrathoracic goiter. GentIeness is most important at this stage, and as the finger sweeps around the capsuIe
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and comes forward, one meets the venous trunks which run from the goiter to the juguIar vein. If the finger is gentIy hooked onto these, they can be caught with snaps, cut and tied at once. This reIieves a great dea1 of the bIeeding which might otherwise be present if th e goiter were quickly extirpated. In some instances it is desirabIe to catch, cut and tie the superior thyroid artery in order to gain greater freedom of motion of the invoIved Iobe of the gIand. This, however, is by no means aIways necessary. With the veins now tied, the finger is gentIy swept around the substerna mass keeping most carefuIIy and gentIy in the proper line of cIeavage. If one gets away from this, hemorrhage occurs or one breaks into the pIeura1 cavity. Therefore, it is most important that adequate time and gentIeness be empIoyed at this stage to free the capsuIe of the mass from the adherent surrounding tissue. In some cases, at this stage of the procedure, the goiter can be somewhat Iifted forward and the inferior thyroid artery seen, caught, tied and cut. In other cases, however, one cannot get at the inferior artery unti1 the mass is fuIIy deIivered from the chest. When the intrathoracic mass is deIivered into the neck, a wet gauze pack is immediateIy sIipped down into the cavity from which it came. This is done to prevent any sudden expulsive cough from causing undue pressure on the pIeura and rupture of the pIeura1 cavity, and aIso to contro1 any ooze from nearby veins that may be occurring. With the goiter now deIivered into the neck and in cIear vision, the course of the inferior thyroid artery can usuaIIy be seen, and occasionaIIy the recurrent IaryngeaI nerve can aIso be seen and more thoroughIy avoided. UsuaIIy, however, the nerve is not seen, and one proceeds at once with the remova of the intrathoracic mass. Due care is taken to avoid injury to the trachea which one must recaI1 may we11 be distorted by the deIivery of the tumor. AIso, great care must be taken to inspect the surface of the mass for parathyroids and to protect
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these and Ieave them behind as one proceeds with the excision of the goiter. When the intrathoracic goiter is removed and hemostasis is complete, a cigarette drain with a very smaI1 amount of gauze protruding is placed into the intrathoracic cavity from which the goiter came. AImost never has it been necessary for us to pack this cavity with gauze, but a drain is desirabIe because not infrequentIy serosanguineous fluid wiII coIIect in the cavity and have to be reIeased if drainage is not instituted at operation. It is our custom to start pulling the drain out slowly on the fourth day and to have it compIeteIy removed on the sixth or seventh day, unIess undue amount of discharge is present. As we have said before, most substerna goiters can be deIivered intact without any rupture of the capsuIe that surrounds them. This is made possibIe by gentIe, sIow dissection with the fingers which IinaIIy encompass the entire goiter, and then the sIow deliverance of the goiter by a Iinger beneath the Iowermost pole. OccasionaIIy, however, the goiter is so large that it cannot be brought through the superior thoracic strait intact, and one can then readiIy put a finger through the capsuIe at the upper portion of the intrathoracic mass and rupture it, permitting the soft, jeIIyIike contents to ooze out. When this has happened, the mass becomes much smaIIer and then aImost invariabIy can be teased up through the superior thoracic strait. The bIeeding which accompanies this rupture of the capsuIe is not great nor troubIesome and is readiIy controhed when the entire tumor is derivered and the major bIood vesseIs are caught and tied.
CONCLUSIONS
Intrathoracic goiter is not an infrequent disease and one with possibIy serious effects if not recognized and treated suff~cientIy earIy. Certain features of the history and physica examination usuaIIy suggest the presence of intrathoracic goiter. The x-ray offers important and frequentIy diagnostic information by reveaIing deviation and compression of the trachea and Iess often the soft tissue mass causing this. With rare exceptions intrathoracic goiters may be removed safely by appropriate surgica1 methods. REFERENCES
MALLER, A. Quoted from Miller, R. B. Large intrathoracic thyroid. Am. J. Roentgenol., 40: 6668, 1938. 2. LINGL, C. Am. J. Roentgenol., 40: 66-68, 1938. 3. DUBOUKG, M. Bull. Sec. Amt. d. Paris, I : 130, 1826 4. ADELMAN, A. Quoted from Wakeley, C. P. S. and Mulvany, J. H. Intrathoracic goiter. Surg., Gy?IeC.@ Obst., 70: 702-710, 1940. 5. MALARD, C. Etude clinique SW Ie goitre plongeant ou retrosternal. Th~sse, Paris, 1879. F. Die Struma Intrathoracica. 6. WUEHRLIAN, Deutsche Ztschr. f. Chir., 43: I, 1896. der k.k. Gesell7. SCHIEFF, A. Oflicielles Protokoll schaft du Aertze. Wien. Min. Wcbnschr., 12: IIII, I.
I899.
8. RIAJOR, R. H. Quoting
Parry, Graves, Basedow. Classical Descriptions of Disease. zd ed. SpringtieId and Baltimore, 1939. Charles C. Thomas. 9. CLUTE, H. M. Diagnosis of substernal goiter. Surg. Clin. N. America, 9: r3o9-1318, 1929. IO. CRILE, G., JR. Intrathoracic goiter. Cleveland Clin. Quart., 6: 313-322, 1939. goiter. Surg. Clin. N. II. LAHEY, F. H. lntrathoracic America,
16: 1613-1629,
1936.
Parathyroids, 12. CROTTE, AUDRE. Thyroid, Thymus. 3d ed., pp. 370-387. Philadelphia, Lea and Febiger.
and 1938.
T
GOITER
CLUTE, M.D. AND KNOWLES B. LAWRENCE, M.D. BOSTON, MASSACHUSETTS
HE fact that certain goiters are partIy or whoIIy intrathoracic is now accepted as a serious and not uncommon pathoIogic condition. When one considers that many of these goiters are compIeteIy hidden in the bony thorax, however, it is not surprising that onIy in recent medica times has much been known of this disease. Intrathoracic goiter was first described anatomicaIIy by A. HaIIer in I 749. l It was much later, in 1830, when C. Ling12 gave the first cIinica1 description of this Iesion. in 1826, recorded an M. Dubourg,3 instance of stranguIation and death due to intrathoracic goiter, and in 1828 A. AdeIman4 reported a case of malignant disease in this type of goiter. The term, “goiter pIongeant,” was coined by MaIard in 185 15 to appIy to those substerna adenomas which popped up into view above the sternum with increased intrathoracic pressure. The monograph, “Die Struma Intrathoracica,” by F. Wuehrman, in r8g66 was the most comprehensive study to that date. The recognition of intrathoracic goiter in the earIier years was, of course, Iimited by the Iack of roentgen diagnosis unti1 1899. At this time Schieff’ added another most important miIestone to the understanding of this disease by showing the vaIue of the x-ray in the diagnosis of intrathoracic goiter. It is interesting today to note that the cIassica1 descriptions of exophthaImic goiter by Parry, Graves, and Basedow, as quoted by Major,8 faiIed to include any case in which the symptoms and signs were those of a goiter extending into the thorax beIow the sternum. This finding is in accord with present day experience that the thyroid gIand in typica exophthaImic goiter rareIy, if ever, extends deeply into the thorax. One cannot but wonder if these writers saw no cases of hyperthyroidism due to a sub-
sterna1 adenomatous goiter which were diffrcuIt of expIanation. ConsiderabIe confusion has existed in descriptions of intrathoracic goiter because of different nomencIatures used by various authors. IncIusion of the terms, “substerna1 ” and “ retrosterna1” and “subcIavicuIar,” under the singIe grouping of “intrathoracic” goiter seems ampIy justified and has been fairIy we11 accepted. From 12 to 30 per cent of a11 goiters couId be so classified according to various reports.1,4,svg Some authors, however, prefer to Iimit the term, “intrathoracic,” to those goiters which extend down to or beIow the arch of the aorta. If this more rigid definition is foIIowed, incidence of intrathoracic goiter ranges from Iess than I to IO per cent of a11 goiters operated upon.10~11,12 Intrathoracic goiter arising from ectopic thyroid tissue deep within the mediastinum is quite rare. The case of Means” in which the mass rested on the diaphragm may faI1 into this category. From embryoIogic considerations such grands shouId Iie in cIose reIationship to the aortic arch or possibIy the trachea1 bifurcation. They may or may not be connected with the thyroid proper by a fibrous cord.’ Ptosis of the norma thyroid gIand, or a sIight dipping down of cervica1 goiter behind sternum or cIavicIes shouId not be cIassified as intrathoracic goiter, since onIy part of such goiters are at best subcIavicuIar. Intrathoracic goiters deveIop when a single adenoma or one or more of the noduIes of a muItipIe adenomatous goiter descend through the superior thoracic strait into the bony thorax, Most frequently intrathoracic goiters arise from adenomatous goiters, but occasionaIIy a single discrete adenoma which once Iay in the Iower poIe of one thyroid Iobe wiI1
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descend into the thorax. The descent of these singIe or multipIe noduIes into the thorax depends first on their Iocation in the gIand. ObviousIy, a discrete noduIe Iocated in the superior poIe of the thyroid gIand wouId not find its way into the chest. When, however, the noduJe is present in the Iower portion of either of the thyroid Iobes or of the thyroid isthmus, it may, as it grows in size, readiIy descend through the superior thoracic strait. One of the factors that influences this descent is the rate of growth which usuaJIy is so sIow that it requires years for the goiter to enter the thorax. It is, of course, occasionaIIy true that a Iow-Iying discrete adenoma in a young person wil1 have a hemorrhage into it, and since the Ieast resistance to its expansion is in the downward direction, it wiII so descend into the chest. Whether the growth of these adenomas of the thyroid is rapid or sIow, there is nothing but Ioose ceIIuJar tissue to restrict their descent into the thorax through the superior strait. Expansion in other directions is Iimited by muscIes, vesseIs or bone. The fascia, descent of these Iow-Iying adenomas is furthermore aided very markedIy by the contractions of the sternomastoid muscIes and of the prethyroid muscles that accompany motions of the head and acts of respiration and degIutition and to some degree by the force of gravity itseIf. ANATOMY
The anatomica relation of intrathoracic goiters is most important, not 0nIy in considering the effects of these thoracic masses upon adjacent structures but also in the surgica1 management of their removal It must be recognized that all, or practicahy aI1, intrathoracic goiters Iie in the cIosest association to the trachea, and this reIationship to the treachea is one of the important factors in their diagnosis and in their surgica1 management. It is perfectIy obvious, when one considers the origin of the intrathoracic masses from an adenomatous enIargement of the thyroid gIand surroundthat the intrathoracic ing the trachea,
portion of the goiter may Iie either to the right, to the Ieft, in front of, or behind the trachea. Furthermore, in some cases the adenomatous mass may entireIv encircIe the trachea with extensions running backward from each Iobe. Most commonIy, intrathoracic goiters extend from the Iower pore of either the right Iobe or the Ieft Jobe of the thyroid directly down aIong the trachea into the superior mediastinum. Less common, in fact quite unusual, is the type in which adenomatous noduIes grow backward between the branches of the inferior thyroid artery and then go downward behind the trachea. This type is occasionaIIy overIooked in goiter operations because the intrathoracic portion Iies out of sight behind the thyroid Iobe in the neck. The arteria1 suppIy to intrathoracic goiters comes from the same arteries that suppIy the norma thyroid gIand. Both the superior and inferior thyroid artery have considerabIe sIackness due to their winding course from the major arteria1 trunk to the thyroid gIand. This is most important, not onIy because it permits portions of the thyroid gIand to descend with their arteria1 suppIy intact but also because it permits contro1 of the bIood suppIy of intrathoracic goiters by controIIing the major thyroid arteries in the neck. The superior thyroid artery, after it Ieaves the externa1 carotid artery, goes up the neck somewhat and then curves downward to join the superior thyroid poIe. The inferior thyroid artery, after it Ieaves the thyroid axis of the subcIavian artery, goes up the neck in quite a wide arch, and after passing beneath the carotid artery and the juguIar vein at a IeveI just below the superior thyroid poIe, descends aIong the gIand and enters it in the Iower or middle portion of the Iobe. It is apparent from this distribution of these two major arteries that if structura1 changes in the thyroid gIand occur, and the lobe or part of the Iobe descends into the chest, there is sufficient laxity in these arteries to permit them to descend with the Iobe. Certainly there is nothing in their
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anatomical arrangement which at the start of the descent of the goiter into the thorax exerts tension to hinder this process. The veins coming from the thyroid gJand empty in Jarge part into the interna juguJar vein, and it seems to be possibJe for these veins aJso to eJongate as part of the thyroid Jobe descends into the thorax. AJmost never have we had any significant Venus bJeeding from within the thorax when a discrete adnomatous mass was Jifted out of the chest. The veins a11 come up with the mass and Jead into the juguJar vein at a JeveJ which usuaJIy is readiJy seen in the operative wound in the neck. These anatomica arrangements of the arteries and veins are most important, then, in the surgica1 remova1 of intrathoracic goiters. The effect that the descent of thyroid adenomas into the thorax has upon the recurrent JaryngeaJ nerve wiJ1 vary, of course, with the Jocation of the thyroid mass before it starts downward into the chest. It is, nevertheJess, true that in most instances, in spite of the presence of deep intrathoracic goiters, there is no voca1 cord paraJysis. In the past it has been said that when voca1 cord paraJysis was present one couJd be quite certain that maJignant degeneration of the intrathoracic mass had occurred. This, however, we now know to be a mistake, because we have severa times seen preoperative paraJysis of one cord in the presence of Jarge substernal goiters in which there was no evidence of maJignancy. Whether the substerna goiter pushes the recurrent JarvngeaJ nerve backward as it descends, or in occasiona cases in which the goiter descends between branches of the inferior thyroid artery, presses it forward, wiJJ of course depend on the point of origin of the goiter. It is our experience, however, that in most cases the recurrent nerve is pushed backward and is we11 out of the way of the surgeon at the time of the operation. PATHOLOGY
Most intrathoracic goiters, as we have said, arise from a muJtipJe adenomatous
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goiter, or the so-caJJed noduJar goiter. Less often they resuJt from the descent into the thorax of a singJe discrete adenoma. Whichever of these two basic pathoJogica1 factors is present, the intrathoracic goiter is subject to the same degenerative changes that may occur in a goiter which is entireJy cervica1 in location. Hyperplasia of the intrathoracic thyroid tissue can occur, and in fact, not infrequentJy does. This resuJts in the deveJopment of toxic symptoms, and we have a cIinica1 picture here very JittJe different from that seen in toxic adenomatous goiter when it is in the usua1 position in the neck. Degenerative changes may occur in the substerna mass with necrosis, hemorrhage and cyst formation. OccasionaJJy, such cysts become very Jarge and produce very serious pressure symptoms. CaJcification in varying degree may occur in the intrathoracic goiter, presumabJy because intrathoracic goiters are goiters which have been present for many years. In some cases maJignant degeneration occurs just as it does in noduJar goiter in the neck. The maJignancy may be diffuse, invading a11 the structures and going outside of the thyroid capsuJe, or it may be JocaJized within a discrete adenoma. It may be of any of the types that one sees in thyroid pathoJogy in the neck. PHYSIOLOGY
Changes in the physioJogy due to the presence of an intrathoracic goiter are reJated first to the possibiJity that hyperthyroidism has deveJoped because of hyperpIasia in the intrathoracic mass. This hyperthyroidism is in no way different, in our experience, from the hyperthyroidism that comes from noduIar goiter in peopIe of middIe Jife and beyond. Its presence, of course, adds distinctJy to the risk of remova1 of the intrathoracic goiter, just as the presence of hyperthyroidism adds appreciabJy to the remova of any Iarge goiter. The changes in the physioJogy which are specificaJJy reJated to the anatomical posi-
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tion of the goiter in the thorax are a11 changes which are due to the presence of an intrathoracic mass, and depend on the
rowed that the patient has a constant stridor on inhaIation. In certain instances the patient finds that there are certain
pressure of this mass on the surrounding structures. The trachea is the earliest organ to show the effect of this pressure. It is deviated from its midIine position by the presence of the substerna mass. If the substerna mass Iies on both the right and the Ieft side of the trachea, then it is, of course, narrowed by this biIatera1 pressure. If the goiter Iies behind the trachea, the trachea may be broadened IateraIIy and at the same time its Iumen narrowed anteroposteriorIy by the enIarging goiter forcing it against the sternum. A simiIar condition may arise when the goiter Iies in front of the trachea and pushes the trachea backward toward the spine. The degree of tracheal pressure wiI1, of course, depend on the size of the substerna goiter and the amount of trachea1 deviation present. In some cases the trachea becomes so nar-
positions of the head in which pressure on the trachea is very much increased and he consciousIy avoids these positions. Thus we have patients who cannot sIeep with their head bent sharpIy forward because this obstructs their breathing. Others cannot lie on one side or the other in bed because again the trachea is bent over the substerna1 mass and is definiteIy narrowed by this mechanica change in its position. It is interesting to observe that very rareIy does a substerna goiter affect the course of the esophagus. PhysioIogicaI effects from the presence of an intrathoracic mass rareIy make any changes on the recurrent IaryngeaI nerve or other nerves in the neck. In a few instances, however, uniIatera1 vocal cord paraIysis has occurred in our experience probabIy due to stretching of the recurrent
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IaryngeaI nerve. The presence of this paraIysis in the recurrent nerve may not be recognized by the patient and wiII be found
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individuaIs that puffiness of the face and duskiness of coIor are distinctIy noticeabIe and very Iarge diIated veins are pIainIy
FIG. 2. (M. R.) An obIiqueIy Iateral x-ray in this case demonstrates deviation of the trachea backward with compression by an intrathoracic goiter at Ievel of the manubrium sterni. At one point the trachea is narrowed to one-third normal diameter. The size of the soft tissue mass is clearly shown.
onIy by routine examination of the voca1 cords. In other instances, however, goiter patients consuIt the physician because of the fact that they have recentIy deveIoped hoarseness and this may be the first symptom of a substerna goiter. In patients who have very Iarge intrathoracic goiters, there is sufficient pressure of the goiter against the venous structures coming down through the superior thoracic strait to produce definite engorgement of the veins in the neck and over the chest waI1. Such venous engorgement is very marked in certain Iarge goiters, and yet, curiousIy enough, in other deep intrathoracic thyroid tumors there wiII be IittIe or no venous engorgement. The venous engorgement may be so marked in some
visibIe over chest waI1.
the
neck
and
upper
anterior
DIAGNOSIS
The diagnosis of intrathoracic goiter can be made, not infrequentIy, from carefu1 consideration of the patient’s history, but in many instances it is made onIy by cIinica1 and x-ray examination. The cIinica1 symptoms that are suggestive of intrathoracic goiter are varied, but most of them are the resuIt of pressure of the intrathoracic mass on the trachea, on veins or on the recurrent IaryngeaI nerve. OccasionaIIy, a patient is seen who says that she had a goiter many years ago, but that it “disappeared.” When a definite sizeabIe mass in the area of the thyroid
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C
FIG. 3. (M. C.) In the anteroposterior x-ray (a) of this patient, the trachea is bareIy visuaIized, but ently nearIy in the midline. A soft tissue mass is shown extending below the aortic arch, particuIarIy right. A lateral film (b) demonstrates marked anterior deviation of the trachea with narrowing of its Barium swaIIow (c) indicates that the goiter Iies behind the esophagus also, this structure being forward with the trachea.
apparon the Iumen. pushed
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“disappears,” one may be very suspicious that it has descended through the superior thoracic strait and so passed from view.
a
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hoarseness, and not infrequently the discovery of paralysis of one voca1 cord by a physician, Jeads to the search for a possibIe
b
(A. F.) Deviation of the trachea backward and to the right by the pressure of an intrathoracic goiter are shown (a) in the Iateral and (b) anteroDosterior x-rays. These are the usual views taken in x-ray diagnosis of intrathoracic goiter.
FIG.
4.
More commonIy the patient’s history states that there has been an increasing sense of pressure in the throat. OccasionaIIy, this pressure takes the form of a Iump in the throat which is noticeable when solid foods are swallowed. In we11 deveIoped intrathoracic goiters the patient notices very definiteIy the stridor and difficuIty of breathing that accompany narrowing of the trachea. When the intrathoracic mass lies on one side of the trachea and pushes the trachea we11 away from the midIine, the patient wiII not infrequentIy state that when she Iies with her head on the side at which the goiter is, she has obstruction in breathing; and when she Iies with her head on the' side away from the goiter, there is less troubIe in breathing. The mechanics of this arrangement are perfectIy IogicaI and readiIy understandable. In some patients the deveIopment of
substerna goiter. In other instances the gradua1 deveIopment over a period of years of increasingIy Iarge veins at the base of the neck and over the upper chest, Iikewise show the possible presence of substerna goiter. In some individuaIs the deveIopment of hyperthyroidism, in the absence of any apparent goiter in the neck, may Iead the physician to search for a substerna goiter. The presence of rea1 hyperthyroidism with no paIpabIe enIargement of the thyroid gIand in the neck shouId make any physician consider the possibility of an adenomatous goiter beneath the sternum in the mediastinum. The physical signs that accompany the presence of substerna goiter are varied. In the norma individua1 one can, with considerabIe practice, paIpate the upper poIe and the Iower poIe of both the right and Ieft Iobes of the thyroid. If the thyroid is
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enIarged, this paIpation of the poIes is much simpIer. If then, in the presence of an adenomatous goiter, one can fee1 the superior poIe on each Iobe, and the inferior poIe on one side, but is quite unabIe to get beneath the inferior poIe and feel its Iower borders on the other side, he at once becomes suspicious, if not certain, that there is a substerna extension and an intrathoracic goiter. In some patients there is a discrete adenoma beneath the sternum which rises in the neck when the patient coughs or sneezes or in any other way increases the intrathoracic pressure. This abiIity of a discrete adenoma in the superior mediastinum to rise up into the neck is not commonIy seen but when present is diagnostic. Intrathoracic goiters, when one can paIpate their superior borders or watch them with the fluoroscope, move up and down with deglutition just as do goiters in the neck. This movement with degIutition helps to differentiate the intrathoracic goiter from intrathoracic dermoids or other tumors. We have never found percussion of the superior mediastinum and increase in the duIIness of this area of great heIp to us in the diagnosis of substerna goiter. Most substerna goiters show, in some degree at Ieast, in the neck, or can be paIpated in the sterna1 notch or just to one side beneath the sternomastoid. When such a mass is feIt and when it rises with degIutition, percussion may heIp the examiner in deciding that there is a Iarger mass beneath the sternum. The diagnosis of substerna goiter can aImost invariabIy be made by satisfactory and adequate x-rays of the superior mediastinum. The x-ray technician must understand that his pictures must be su&ientIy soft to show the outline of the trachea, and the patient must have the trachea fiIIed with air and hoId his breath whiIe the picture is taken. It is very important that not onIy anteroposterior views of the trachea and the superior mediastinum are taken, but aIso that IateraI views as we11 are obtained.
OCTOBER, ,911
A discrete adenoma Iying just beneath the manubrium of the sternum and directIy on the trachea may make no great impression on the anteroposterior picture of the trachea, and certainIy the trachea wiI1 not be deviated either to the right or the Ieft of the midIine. However, a IateraI view of the trachea in this same case wiI1 show its marked deviation posterioraIIy, due to the presence of this goiter in front of it. A simiIar situation is obtained when the goiter is behind the trachea and pushes the trachea forward rather than IateraIIy. In some instances x-rays are taken whiIe the patient is swaIIowing a barium mixture, in order to show the reIation of the esophagus to the trachea and to the goiter. This has been very heIpfu1 to show the position of the intrathoracic mass. In many cases of intrathoracic goiter, the goiter itseIf wiI1 not show in the x-ray and its presence wiI1 be known onIy because of its deviation from the norma position in the midIine of the trachea. In other cases, however, when the goiter is very Iarge or when it contains much caIcified material, the actual shadow of the goiter itseIf wiI1 be visibIe; and as x-ray technicians become more expert in their trachea1 pictures, the actua1 shadow of the goiter is more IikeIy to appear in the pIates. TREATMENT
The treatment of intrathoracic goiter is surgica1 remova1, and it is unnecessary to state that the earIier in the course of deveIopment of a substerna goiter surgery is undertaken, the easier, simpIer and safer is the surgica1 procedure. It has been surprising to us to note in many instances the size of intrathoracic goiters that can be removed through the superior thoracic straits without cutting the sternum or freeing the sternocIavicuIar articuIation. In fact, the senior writer in his entire experience has never had occasion to enIarge the bony thoracic strait for the remova of a substerna goiter, nor has he yet encountered such a Iarge noncancerous intrathoracic goiter that it couId not be re-
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moved without enIarging the bony thoracic straits. The anesthesia for the remova of intrathoracic goiters is, of course, of the utmost importance. Here particuIarIy is it necessary to have an anesthetist trained in goiter surgery, and adept in handIing the specific probIems that arise when a trachea is distorted in position and narrowed in its caIiber. We now prefer, and routineIy use, intratrachea1 anesthesia with cycIopropane and oxygen for anesthetic agents. This is the most satisfactory arrangement in our experience. The onIy objection to it, and it is not a serious one, is that the intratrachea1 catheter is somewhat stiff and somewhat resistant when one is attempting to disIocate the intrathoracic mass; and it does not bend and give as much as the trachea wouId if the catheter were not inside of it. However, the fact that anoxemia cannot occur and that the patient’s respiratory process is under the contro1 of the anesthetist, far outbaIances the sIight mechanica1 objection to the catheter in the trachea. The first requirement in the surgica1 remova of an intrathoracic goiter is a wide incision. The usua1 transverse cervica1 incision is made above the cIavicIe, the skin ffap Iifted and the muscIes split in the midIine IongitudinaIIy. The sternomastoid is then freed from the prethyroid muscIes on each side, and the prethyroid muscIes are cIamped and cut on each side, even though the substerna goiter is present on onIy one side. This cutting of the muscIes on the uninvoIved side is not necessary in smaI1 tumors, but in Iarge growths it is very heIpfu1, because it gives a great dea1 of freedom for the Iobe of the thyroid on that side to move when the manipuIations for the extirpation of the goiter in the chest are going on. When the fieId is thoroughIy exposed by wide cutting of the prethyroid muscIes and thoroughIy dry, a carefuI expIoratory finger is pIaced aIong the posterior surface of the capsuIe covering the intrathoracic goiter. GentIeness is most important at this stage, and as the finger sweeps around the capsuIe
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and comes forward, one meets the venous trunks which run from the goiter to the juguIar vein. If the finger is gentIy hooked onto these, they can be caught with snaps, cut and tied at once. This reIieves a great dea1 of the bIeeding which might otherwise be present if th e goiter were quickly extirpated. In some instances it is desirabIe to catch, cut and tie the superior thyroid artery in order to gain greater freedom of motion of the invoIved Iobe of the gIand. This, however, is by no means aIways necessary. With the veins now tied, the finger is gentIy swept around the substerna mass keeping most carefuIIy and gentIy in the proper line of cIeavage. If one gets away from this, hemorrhage occurs or one breaks into the pIeura1 cavity. Therefore, it is most important that adequate time and gentIeness be empIoyed at this stage to free the capsuIe of the mass from the adherent surrounding tissue. In some cases, at this stage of the procedure, the goiter can be somewhat Iifted forward and the inferior thyroid artery seen, caught, tied and cut. In other cases, however, one cannot get at the inferior artery unti1 the mass is fuIIy deIivered from the chest. When the intrathoracic mass is deIivered into the neck, a wet gauze pack is immediateIy sIipped down into the cavity from which it came. This is done to prevent any sudden expulsive cough from causing undue pressure on the pIeura and rupture of the pIeura1 cavity, and aIso to contro1 any ooze from nearby veins that may be occurring. With the goiter now deIivered into the neck and in cIear vision, the course of the inferior thyroid artery can usuaIIy be seen, and occasionaIIy the recurrent IaryngeaI nerve can aIso be seen and more thoroughIy avoided. UsuaIIy, however, the nerve is not seen, and one proceeds at once with the remova of the intrathoracic mass. Due care is taken to avoid injury to the trachea which one must recaI1 may we11 be distorted by the deIivery of the tumor. AIso, great care must be taken to inspect the surface of the mass for parathyroids and to protect
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these and Ieave them behind as one proceeds with the excision of the goiter. When the intrathoracic goiter is removed and hemostasis is complete, a cigarette drain with a very smaI1 amount of gauze protruding is placed into the intrathoracic cavity from which the goiter came. AImost never has it been necessary for us to pack this cavity with gauze, but a drain is desirabIe because not infrequentIy serosanguineous fluid wiII coIIect in the cavity and have to be reIeased if drainage is not instituted at operation. It is our custom to start pulling the drain out slowly on the fourth day and to have it compIeteIy removed on the sixth or seventh day, unIess undue amount of discharge is present. As we have said before, most substerna goiters can be deIivered intact without any rupture of the capsuIe that surrounds them. This is made possibIe by gentIe, sIow dissection with the fingers which IinaIIy encompass the entire goiter, and then the sIow deliverance of the goiter by a Iinger beneath the Iowermost pole. OccasionaIIy, however, the goiter is so large that it cannot be brought through the superior thoracic strait intact, and one can then readiIy put a finger through the capsuIe at the upper portion of the intrathoracic mass and rupture it, permitting the soft, jeIIyIike contents to ooze out. When this has happened, the mass becomes much smaIIer and then aImost invariabIy can be teased up through the superior thoracic strait. The bIeeding which accompanies this rupture of the capsuIe is not great nor troubIesome and is readiIy controhed when the entire tumor is derivered and the major bIood vesseIs are caught and tied.
CONCLUSIONS
Intrathoracic goiter is not an infrequent disease and one with possibIy serious effects if not recognized and treated suff~cientIy earIy. Certain features of the history and physica examination usuaIIy suggest the presence of intrathoracic goiter. The x-ray offers important and frequentIy diagnostic information by reveaIing deviation and compression of the trachea and Iess often the soft tissue mass causing this. With rare exceptions intrathoracic goiters may be removed safely by appropriate surgica1 methods. REFERENCES
MALLER, A. Quoted from Miller, R. B. Large intrathoracic thyroid. Am. J. Roentgenol., 40: 6668, 1938. 2. LINGL, C. Am. J. Roentgenol., 40: 66-68, 1938. 3. DUBOUKG, M. Bull. Sec. Amt. d. Paris, I : 130, 1826 4. ADELMAN, A. Quoted from Wakeley, C. P. S. and Mulvany, J. H. Intrathoracic goiter. Surg., Gy?IeC.@ Obst., 70: 702-710, 1940. 5. MALARD, C. Etude clinique SW Ie goitre plongeant ou retrosternal. Th~sse, Paris, 1879. F. Die Struma Intrathoracica. 6. WUEHRLIAN, Deutsche Ztschr. f. Chir., 43: I, 1896. der k.k. Gesell7. SCHIEFF, A. Oflicielles Protokoll schaft du Aertze. Wien. Min. Wcbnschr., 12: IIII, I.
I899.
8. RIAJOR, R. H. Quoting
Parry, Graves, Basedow. Classical Descriptions of Disease. zd ed. SpringtieId and Baltimore, 1939. Charles C. Thomas. 9. CLUTE, H. M. Diagnosis of substernal goiter. Surg. Clin. N. America, 9: r3o9-1318, 1929. IO. CRILE, G., JR. Intrathoracic goiter. Cleveland Clin. Quart., 6: 313-322, 1939. goiter. Surg. Clin. N. II. LAHEY, F. H. lntrathoracic America,
16: 1613-1629,
1936.
Parathyroids, 12. CROTTE, AUDRE. Thyroid, Thymus. 3d ed., pp. 370-387. Philadelphia, Lea and Febiger.
and 1938.