The surgical management of substernal and intrathoracic goiter

THE SURGICAL MANAGEMENT INTRATHORACIC ALEXANDER W. BLAIN, M.D. Professor of Chical

Surgery,

Wayne

AND

OF SUBSTERNAL AND GOITER* ALBERT

DETROIT,

UCH has been written on substernaI and intrathoracic goiter in recent years but the terminoIogy has been indefinite. They are not synonymous terms but more recently the Iiterature has been Iess confusing. If we are abIe to adhere strictIy to the term “intrathoracic goiter,” we must then consider onIy those within the thoracic cage as true intrathoracic goiters. Those that extend through the thoracic aperture are considered as partiaI intrathoracic goiters. However, in reviewing the Iiterature one notes that any goiterous tumor that extends into the thoracic cage and remains in that position even after coughing or swaIIowing or forced expiration is considered an intrathoracic goiter. If one adheres to this cIassification, the incidence of true intrathoracic goiter wiII be found to be Iess than I per cent. PartiaI intrathoracic goiter has a greater incidence, ranging from 25 to 30 per cent in the goiterous areas and IO to 15 per cent in non-goiterous areas. CriIe’ reported an incidence of Iess than I per cent and Hunt2 reported three cases of tota intrathoracic goiter in a series of 651 cases. Curtis3 reports the incidence of tota intrathoracic goiter as between I and 2 per cent. In a series of 4,006 cases at the Mayo Clinic reported by Pemberton4 0.6 per cent were intrathoracic and 13.5 per cent partia1 intrathoracic goiters. The ratio of intrathoracic goiter in male and femaIe remains the same, about one to five as any adenomatous goiter. The age incidence averages at about forty-five years. It is rareIy found beIow the age of twenty, but is not infrequent after sixtyfive. One of our oldest operative patients

M

*From the Department

DEMATTEIS,

Resident

University

M.D.

in Surgery

MICHIGAN

was eighty-three years, with a Iarge partia1 intrathoracic goiter. Intrathoracicgoiters are, as Lahey” states, adenomas which deveIoped from a smaI1 adenoma in the Iower poIe of either Iobe of the thyroid. Lahey, in more than 14,000 thyroidectomies, has never seen an intrathorax primary hyperthyroid with true hyperpIasia. ANATOMICAL CONSIDERATIONS The descent of the enIarging adenoma into the thorax is aided by the upward and downward motion of the thyroid in the act of swaIIowing. Its downward growth, beIow the sternum, is a natura1 course since it is the site of Ieast resistance. On its anterior surface it encounters great resistance from the “ribbon ” muscIes, nameIy, the sternohyoid, sternothyroid and omohyoid; and aIso from the sternocleidomastoid. Its descent downward is onIy resisted by the deeper fascia1 pIanes, but these are carried downward through the thoracic aperture and into the superior mediastinum. However, the thoracic aperture is narrow and in order for the adenomas to become Iarger it must descend deeper into the thorax. In doing so it increases its transverse diameter, a point which is of great importance when it is removed. The depth it may attain is, of course, variabIe but severa cases are reported in which it has aImost reached the IeveI of the arch of the aorta. What happens to the trachea is dependent upon the size of the gIand. The iIIustration (Fig. I) shows the distortion and Iateral compression of the trachea. Here one can see how the trachea is distorted and how the Iumen is constricted. This accounts for the

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mosi t prc eminent symptoms of substernal and intra ,thoracic goiter, namely, dyspnea and chok :ing sensation. It also brings out

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venous return of the superior vena c:ava. The other symptoms of thyroid dise ,ase,7 such as nervousness, tachycardia and

FIG. I. Partially sub-sternal goiter.

one point in the diagnosis that has been stressed by Lahey, which is the shifting of the thyroid cartilage away from the midline. The result of pressure exerted by the mass on the trachea produces the most serious and alarming symptom. AIso, it causes the choice of anesthesia to be a problem which must be carefully considered. SYMPTOMS

Symptoms .of intrathoracic thyroid are dyspnea due to distortion and compression of the trachea; dysphagia due to direct pressure of the goiter upon the esophagus; edema of the neck and head is sometimes present in large intrathoracic goiters due to the pressure of the gland upon the

tremor are present to a varying degree, depending upon the amount of toxicity present and, although Lahey has stated that few, if any, of these goiters are truly primary hyperthyroid goiters, a certain amount of hyperthyroidism is present in a surprisingly high number of cases. This, we believe, is evidenced by the high basal metabolism rate, tachycardia and tremor. It is true that all of the complete intrathoracic goiters do not present toxic symptoms but certainry a great number of the partiaI or incomplete intrathoracic goiters show signs of hyperthyroidism. Although the dysphagia and dyspnea may be present for a’ number of years they do not become severe ,until the last few months of the

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disease when the symptoms become so aIarming that the patient seeks the aid of the surgeon.

FIG. 2. Trachea1

compression

Autiusr, 1c)45

mucus coIIecting in the trachea, the patient is then free to cough and remove the mucus. It wilI aIso serve as a guide in

due to tumor masses at various IeveIs.

ANESTHESIA

The type of anesthesia most commonIy empIoyed in this cIinic is IocaI infiItration anesthesia. This has been satisfactory in practicaIIy a11 of our cases. However, when the symptoms due to distortion of the trachea are present one must seriously consider the use of an intratrachea1 catheter of the hard rubber type with ether as one of the inhaIation anesthetics. This will aIIow more manipuIation of the tumor mass as it is being removed without further compression of the trachea and the fear of mucus secretion can be handIed quite easiIy. Many cIinics use cervica1 bIock anesthesia with exceIIent resuIts,g whiIe some stiI1 use nitrous oxide and oxygen.lO Ethylene cycIopropane is aIso an exceIIent anesthesia, but the advantages of IocaI infiItration or &rvicaI bIock far outweigh the genera1 type of anesthesia in that one has fuI1 contro1 of the patient during the operation. ShouId any diffIcuIty arise with

determining the status of the recurrent IaryngeaI nerve. When using nitrous oxide and oxygen on a patient who has considerabIe narrowing of the trachea, diffIcuIty is encountered if the constriction does not permit enough oxygen to be carried through into the Iungs. Lahey has advised, in these cases, the use of an oxygen-heIium mixture. The heIium is a good vehicIe and the mixture is of much Iower moIecuIar weight and can be transported through the constricted trachea much easier. TECHNIC

The technic used in the remova of such tumors is about the same as that advised by other men, such as Lahey, CriIe and Hunt. A Iow coIIar incision is made and adequate exposure is essentia1. The ribbon muscIes are transversely severed and retracted away from the fieId of operation. CriIe did not Iike the idea of cutting the muscIes, but most others, as we11 as we in

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this clinic, usuaIIy do so and the postoperative cosmetic resuIts are comparabIe to those in which the muscIes have not been

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the middIe thyroid vein. If much capilIary oozing is anticipated preoperativeIy oxalic acid is used as an adjunct to hemostasis.12

FIG. 3. Sub-sterna1 goiter (G. B., age eighty, July, 1944).

severed. One must remember that the bIood suppIy to the thyroid gIand comes from the superior and inferior thyroid arteries. The venous return is through the superior, middIe and inferior thyroid veins. Therefore, if ligation is first made on the superior thyroid artery and vein, reIativeIy Iittle bIeeding will be encountered unti1 the dissection is carried on to the IeveI of

The gIand is then brought forward, exposing these veins, which are cIamped and Iigated, thus permitting greater traction on the gIand. The procedure in the removal of the gland shouId be carried out within its fibrous capsuIe. This wiII prevent injury to the recurrent IaryngeaI nerve, which lies just beIow the capsuIe and hugs the trachea. The intrathoracic portion,

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which is the most dif%cuIt to remove, can be approached by one or two methods. Lahey uses the method he devised some

and thoracic fascia. The finger is brought down to the base of the gIand if possibIe. As he makes traction with the Lahey clamp

FIG. 4. X-ray (retouched) showing compression of trachea.

years ago in which he inserts the index finger posterior to the adenoma, passing it within the capsuIe and the Ioose intraceIIuIar tissue Iying adjacent to the cervica1

from above, he also forces the gland upward through the thoracic aperture with his finger. In doing so the inferior thyroid artery can be handIed in one of two ways,

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the tumor is deIivered, there wi:I1 be a sudden reIease of negative pressure 2 with Iin the cavity occupied by the gIand, causr ng

i.e., Iigating it as it is exposed when deIivering the tumor, or, at the beginning of the proc :edure (instead of passing the finger

FIG. 5. X-ray

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doa m to the base of the gIand), bringing the finger forward and exposing the artery. Thi s latter method is perhaps not the safe !st method but can be carried out. As

after

removal

of thyroid

tumor.

a re-expansion and shifting tinum back into its normaI ever, a smaI1 cavity wiII upper mediastinum and

of the medi; aspositio n. Ho remain in t :: this sh’ouId be

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packed with dry gauze, not onIy to permit hemostasis but aIso to serve as a drain, thereby keeping the cavity dry. Another

FIG. 6. MorceIIation

method, which is aIso advised by Lahey, and which is used to great advantage in the true intrathoracic goiter, is passing the finger directIy into the gland, breaking

Aucus-r, ~945

up the gIanduIar tissue and removing it, thereby reducing the voIume of the tumor and aIlowing it to be deIivered quite easiIy.

with radio knife.

A method that is sometimes used in this clinic is morceIIation of the gIand, thereby reducing its size and removing the adenoma in piece-mea1 fashion. The vesseIs are

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ligated as approached. This method has one advantage of importance. Though the gland is removed in pieces from its thoracic site, bIeeding is more easily controILed and the danger of breaking through adhesions containing bIood vessels when passing the finger around the gland is greatly minimized. BIeeding here is quite serious and hard to manage as one can imagine, and, therefore, morceIIation may avoid this danger. The desire of a surgeon to remove a tumor intact as a specimen is great, but when morceIIation makes the removal much easier then it should be done. It is far more desirable to make the procedure life-saving to the patient than to save a good specimen. When one uses one of the Iatter two methods he must be extremeIy careful in not aHowing any of the gIanduIar tissue to remain within the thoracic cavity, since this is an excelrent medium for infection in causing mediastinitis. The drains mentioned previousIy are not removed in two days but are graduaIIy taken out over a period of five to eight days. In doing so the accumuIation of serum which often accompanies foIIowing the remova of such tumors wiI1 be avoided.

I. A distinction in nomencIature shouId be drawn between substerna and intrathoracic goiter. 2. MorceIIation of the tumor facilitates the remova and renders the procedure safe. 3. As in a11 goiter operations the finger shouId not be swept around the gland but the gIand should be pIaced under traction with forceps. In this way the operation is not a blind operation and if the smaIIer

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organ is removed graduaIIy anomaIous vesseIs can be observed and Iigated. 4. Morcellation can be accompIished by removing part or a11 of the tumor within the gIand by bIunt dissection. In some cases the radio knife can be used to advantage-graduaIly cutting away the center of the mass with the coaguIating current. 5. The objection to morceIIation, except in maIignancy,‘” is answered by the statement that the operation is designed to cure the patient-not to save a good pathoIogica1 specimen. REFERENCES

I. CRILE, GEORGE, JR. Tumors of latera aberrant thyroid origin. J. A. M. A., I 13: 1094-1097, 1939. 2. HUNT. CLAUDE J. The diagnosis and management of partial and total intrathoraci goiter. 2-r. West. Surg. Ass., 465-474, 1939. 3. CURTIS, G. M. Intrathoracic goiter. J. A. M. A., 96: 737-41, ‘931. 4. PEMBERTON, J. DEJ. 5. 6.

7. 8.

CONCLUSIONS

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13.

Surgery of substernal and intrathoracic goiters. Arch. Surg., I I : 1-20, 1921. I.AHEY, FRANK H. Intrathoracic goiter. J. A. M. A., 113: 1098-I 104, 1939. BLAIN, ALEXANDER W. Embryology, anatomy, histoIogy and chemistry of the thyroid gland. Internat. J. Surg., 29: I 17-r 19, 1916. BLAIN, ALEXANDER W. Diseases of the thyroid gland. Internat. J. Surg., 29: 46-47, 1916. BLAIN. ALEXANDER W. A clinica study of genera1 anesthesia. New York M. J., May 9, 1908. JACKSON, ARNOLD S. Intrathoracic goiter. Jackson Chl. Bull., 6: 43-51, 1944. BLAIN, ALEXANDER W. Nitrous-oxide-oxygen anesthesia in major surgery. J. Micb. State Med. Sot.,, November, 1922. BLAIN, ALEXANDER W. The surgica1 aspects of goiter with specia1 reference to pressure symptoms. Internat. J. Surg., 24: 43-49, 191I. BLAIN, ALEXANDER W. and CAMPBELL, KENNETH N. Hemostatic effect of oxalic acid; clinical and experimentaI resuhs, with a review of the Iiterature. Arch. Surg., 44: I 117-1125, 1942. BLAIN, ALEXANDER W. Malignant tumors of the thyroid pIand. Internat. J. Surg., 26: 166169, 1913.