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Assessment and management of cervico-mediastinal goiter
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ARTICLE IN PRESS European Annals of Otorhinolaryngology, Head and Neck diseases xxx (2017) xxx–xxx
Available online at
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Review
Assessment and management of cervico-mediastinal goiter E. Brenet ∗ , X. Dubernard , J.C. Mérol , M.A. Louges , M. Labrousse , M. Makeieff Département d’otorhinolaryngologie et chirurgie cervico-faciale, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
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Keywords: Goiter Sternotomy Retrograde dissection of the inferior laryngeal nerve
a b s t r a c t Cervico-mediastinal goiter is a particular entity from the point of view of thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and perform a painstaking preoperative work-up, so as to draw up fully-fledged plan. CT is now indispensable, to anticipate risks and determine whether sternotomy is needed. Surgery seems to induce more postoperative complications than in conventional surgery, although they can be reduced by retrograde dissection of the inferior laryngeal nerve and downward dissection of the posterior side of the lobe to optimize control of adjacent structures. This surgery requires optimal teamwork between all of the specialties involved in patient management: medical, radiological, anesthesiological and surgical. © 2017 Elsevier Masson SAS. All rights reserved.
1. Introduction Thyroidectomy is a well-codified procedure under normal circumstances, but the presence of substernal goiter (SSG) requires the surgeon to adapt technique intraoperatively [1,2]. SSG is defined clinically and/or radiologically as extension of the thyroid below the sternal fork when the patient is in supine position [3]. This is an anatomic definition and does not help the surgeon anticipate intraoperative problems. It may not be possible to palpate the inferior end of the goiter in the lower part of the neck without aggravating the difficulty of surgery. The scope of difficult thyroidectomy has recently been updated to include SSG [4], covering factors liable to cause surgical problems: • topographic: cervico-thoracic and ectopic intrathoracic goiter; • technical: auto-immune thyroiditis, locally advanced cancer, recurrence; • anatomic: “non-recurrent recurrent nerve”, preoperative recurrent nerve palsy. We thus define SSG as a thyroid gland with inferior prolongation necessitating specific extraction maneuvers liable to increase surgical risk. Two entities can be distinguished in SSG: cervico-thoracic goiter (CTG) and intrathoracic goiter (ITG), the latter featuring the development of ectopic thoracic thyroid tissue, with no continuity with
the cervical tissue. CTG shows exclusively thyroid vascularization, whereas ITC is not only more rare (< 1% of goiters) but also shows specifically thoracic vascularization (internal thoracic artery, aorta, etc.) [4], and thus comes within the field of thoracic surgery, with specific approaches [5]. 2. Pathophysiology Causes leading to goiter are multiple: genetic, toxic (smoking), natural (manioc) and environmental (iodine deficiency), autoimmune thyroid disease and cancerous, hormonal or infiltrating pathology [6]. Thoracic extension in CTG is progressive, toward regions of lower anatomic resistance behind and forward of the supra-aortic vessels. Anterior extension is the most frequent at about 75% of CTGs [4]. It is more rapidly compressive, hindered in its inferior development by the brachiocephalic artery. CTGs with posterior development can become quite large, without clinical impact or symptoms, as there is a large space posterior to the brachiocephalic artery. Leftward development of posterior goiter is blocked inferiorly by the aortic cross and laterally by the common carotid and subclavian arteries (Fig. 1), and extension is rather inter-tracheoesophageal or retro-esophageal, giving rise to a typical scarf aspect. This form is rare, but not altogether exceptional at about 3% of cases; it makes surgery especially complex. 3. Preoperative work-up [7] 3.1. Clinical assessment
∗ Corresponding author. 6, rue de l’Ecu, 51100 Reims, France. E-mail address: [email protected] (E. Brenet).
The most common symptom is dyspnea, found in 59% of cases: in 39% as a feeling of being short of breath and in 20% as positional
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Fig. 3. Contrast-enhanced cervico-thoracic CT, axial slice: large substernal goiter extending under the aortic arch.
Fig. 1. Cervico-thoracic region: goiter extension, paths (right and left arrows). Right: passage behind brachiocephalic artery (white star). Left: downward extension blocked by aortic arch (black star) and common carotid artery (white hexagon), therefore passing behind the esophagus or trachea.
dysthyroidism, which is a risk factor for surgical difficulties [4]. Thyroglobulin assay is not recommended. Calcitonin assay is performed preoperatively in case of suspected risk of thyroid medullary carcinoma [7]; false positives underlying calcitonin elevation comprise Hashimoto thyroiditis, chronic kidney failure, or hypercalcemia [14,15]. 3.3. Radiologic work-up
Fig. 2. Cervico-thoracic goiter, patient in operative position: obese short-necked patient; Note superficial venous circulation, indicating superior vena cava syndrome.
dyspnea. The second most frequent symptom is dysphagia, found in 43% of cases, mainly concerning solids, and sometimes associated with pharyngolaryngeal reflux [8]. Dysphonia is less frequent, but requires preoperative indirect laryngoscopy to assess vocalfold mobility; this examination is especially important in revision surgery or if the patient has already undergone cervico-thoracic surgery [9]. Goiter volume is assessed on the WHO classification. Contrastenhanced cervico-thoracic CT scan is recommended to screen for substernal extension, if the goiter is not entirely palpable, notably in patients who are obese, have a short neck or present kyphoscoliosis [10]. Superior vena cava syndrome is found directly in 5–9% of cases [8,11] (Fig. 2), or may be revealed by Pemberton’s maneuver, with the face turning crimson when the patient holds his or her arms above the head for a few minutes [12,13]. 3.2. Biological work-up Assays of TSH, thyroid hormones and TSH-receptor, thyroperoxidase and thyroglobulin antibodies reveal autoimmune
First-line imaging is by ultrasound, even in clinically manifest goiter [16]. Fine-needle aspiration of ultrasound-suspect nodules follows the indications for management of a normal-sized thyroid [17]. An intracavity probe assesses substernal extension. Contrast-enhanced CT scan is the gold-standard for cervicomediastinal exploration. Vascular exploration focuses in detail on the relations between the goiter and the aortic arch, common carotid artery, brachiocephalic artery, subclavian artery and the two brachiocephalic veins. Goiter descending below the aortic arch is difficult to extract and thus entails a risk of sternotomy [18] (Fig. 3). Exploration screens for a retro-esophageal subclavian artery that may be induce dysphagia lusoria and is systematically associated with a “nonrecurrent right recurrent” nerve, originating from the vagus nerve in the upper neck, which is a major surgical pitfall [19]. Digestive exploration screens for tracheo-esophageal dissociation in case of “scarf goiter” and also for radiologic tracheal compression, found in 35–97% of cases, depending on the report [8,20]. Surgery is indicated for ≥ 35% tracheal stenosis and achieves significant alleviation of dyspnea in 95–98% of cases. In < 35% stenosis, surgery is indicated only in case of clinical symptoms or in young patients to prevent any potentially harmful medium-to-long-term progression [20]. Iodine-131 scintigraphy is recommended only if TSH levels are below normal. 4. Revelation and surgical indications Age is the first parameter to consider. Asymptomatic goiter in a patient of advanced physiological age is not in itself an indication for surgery. In young patients, on the other hand, the risk of the goiter growing and becoming compressive or malignant justify surgery even in the absence of symptoms [21]. In case of symptom onset, a complete assessment work-up is mandatory. Acute respiratory distress, dysphagia or signs of vascular compression provide brutal revelation and require rapid and difficult treatment. Such situations may arise with an episode of hyperthyroidism, hematocele or oncologic degeneration (e.g., anaplasia). It is estimated that 1–3% of patients with untreated plunging goiter
Please cite this article in press as: Brenet E, et al. Assessment and management of cervico-mediastinal goiter. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), http://dx.doi.org/10.1016/j.anorl.2017.06.001
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die from respiratory causes, whence the need to operate on young asymptomatic patients [22,23]. CT assessment is essential, to identify the goiter and its vascular relations and detect any invasion of the visceral axis that might lead to tumoral transformation, such as anaplasia, often contraindicating surgery [10]. In patients with history of surgery, scar tissue in the thyroid fossa promotes development of the goiter toward the cervicothoracic isthmus on remaining or overlooked thyroid tissue [1,17,23]. Finally, it is important during the work-up to identify any factors predictive of need for sternotomy. Clinically, SSG of more than 160 months’ progression is an important risk factor. Radiologically, high thyroid tissue density, retrovascular goiter location and extension below the carina increase the risk of sternotomy, with relative risk of 47.3, 10.5 and 20.5, respectively [24]. Other sternotomy risk factors have been reported: extension below the aortic arch (PPV, 54%; NPV, 97%), predominantly right-side location (PPV, 21%; NPV, 95%), or retrotracheal location [25]. Surgical indications should systematically be discussed in the multidisciplinary team, taking account of the opinions of the patient’s physician, the patient, the endocrinologist, the anesthesiologist and the cervical and thoracic surgeons [18]. 4.1. Preoperative thoracic consultation and patient information Sternotomy is rare, at 1% to 3% of cases [4,18,26], but needs to be anticipated. A preoperative consultation with the thoracic surgeon is recommended in case of history of radiation therapy or neck surgery, suspected malignancy with extra-thyroidal extension, extension below the aortic arch or to the posterior mediastinum, or ectopic mediastinal goiter without connection to the cervical goiter [7]. The consultation allows the patient to be informed of the possibility, modalities and consequences of sternotomy [18,27]. 5. Cervico-thoracic goiter surgery Cervico-thoracic goiter surgery is complex and can only be performed in reference centers with experienced surgical and anesthesiological teams [28,29]. 5.1. Intubation Intubation is performed by an experienced anesthesiologist in difficult indications, although SSG entails no specific difficulties of intubation [30]. The surgeon should be on hand during induction, and teamwork with the anesthesiologist should be optimal. In case of foreseeable difficulties (with pharyngolaryngeal involvement or obesity), intubation should be performed with the patient awake, under flexible endoscopy [31]. A probe is positioned to monitor recurrent nerve activity [32]. 5.2. Surgery The objective is to extract the entire goiter through a cervical approach, with optimal control of large vessels. Cervico-thoracic goiter surgery differs from conventional thyroid surgery in two ways: it includes location and retrograde dissection of the inferior laryngeal nerve and raising the goiter to the cervical region through the anterior part of the superior thoracic orifice. The veins in particular are exposed: notably, the brachiocephalic vein in anterior goiter and the azygos vein in deep goiter. Controlling vascular problems before raising the goiter can be difficult and chancy and may require emergency sternotomy to enable access [33]. It is therefore important for the surgeon to be precisely
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aware of vessel size, prolongations and relations to large vessels [33,34]. The patient is positioned with the arm along the body and neck in hyperextension, with a support under the shoulders if necessary. A medial cervical incision of a length corresponding to the goiter is made along the sternal manubrium. When the cervical white line is found, it is incised from the hyoid bone down to the sternal manubrium. The superficial and deep infrahyoid muscles are pulled aside by retractors after release from the thyroid capsule underneath and may be sectioned if exposure requires. Dissection begins on the less plunging side, performing the first lobotomy then freeing the anterior and lateral side of the trachea by sectioning Grüber’s ligament to the contralateral side. Dissection then continues downward, releasing the anterior part of the goiter from its tracheal attachments, allowing a second step, which is to raise the thoracic prolongation of the goiter. The superior end of the lobe is exposed and the superior thyroid artery is ligated, taking care not to involve the superior laryngeal nerve, which sometimes descends to a greater or lesser extent on the superior end of the lobe and can easily be injured if it becomes detached. A traction wire is positioned on the superior end of the lobe. Dissecting the superior end provides access to the posterior retrothyroid plane and lateral side of the lobe. The inferior laryngeal nerve is then located, moving downward from its entry point in the larynx. This retrograde dissection enables the nerve to be located and dissected when it is not exposed laterally by inclining the lobe. Goiters may be too large and hard for a conventional technique without risk of recurrent nerve lesion [2,10,35]. The inferior laryngeal nerve is located under the edge of the cricoid cartilage and just behind the inferior horn of the thyroid cartilage. The cricopharyngeal muscle, covering the cricoid is followed down to its inferior edge, from which the inferior laryngeal nerve has to be explored downward. The lobe, held down by a retractor, delineates a triangular anatomic area comprising the inferior edge of the cricopharyngeal muscle above, the trachea within and the esophagus below. This stage of dissection is closest to the nerve, adherent to the thyroid capsule and hemostasis should, if possible, be avoided until the inferior laryngeal nerve has been identified. Once identification has been confirmed by neurostimulation, the nerve is followed downward. This retrograde dissection significantly reduces the risk of transient or permanent inferior laryngeal nerve palsy in goiter surgery [2]. The thyrotracheal attachments are then sectioned and the inferior thyroid artery is located, ligated and sectioned (Fig. 4). The plunging part of the goiter is then lifted by the index finger, which is placed on the capsule, and slid along the posterolateral side of the lobe down to the inferior end then up over the anterior side until a resistance, indicating the inferior thyroid veins, is encountered (Fig. 5). The lobe is raised and the veins are controlled after “delivering” the lobe. Bleeding occurring before extraction can hinder control [36] and this is when sternotomy may become necessary. Drains may not be necessary and do not reduce compressive cervical hematoma or provide faster detection [37], but are used with obese patients or in case of kyphoscoliosis, where clinical surveillance is less reliable [38]. Closure is then performed in the classical way.
6. Postoperative course Surveillance should be close during the first 24 hours. Extubation is performed in the operating room, in presence of the surgeon. Tracheomalacia secondary to cartilage ring compression by the goiter is very rare. Techniques such as tracheal resection-anastomosis, endotracheal implant or tracheopexy are
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Thyroid hormone replacement is initiated on the day after surgery, at 1.4–1.6 g/kg/day. TSH assay at 4–6 weeks guides replacement dosage. 7. Conclusion
Fig. 4. Release of thyroid lobe after retrograde inferior laryngeal nerve dissection (arrow) and control of inferior thyroid artery (star).
Cervico-thoracic goiter is a particular entity in thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and above all, perform thorough preoperative assessment so as to draw up a full intervention plan. CT is now indispensable, enabling the patient to be given clear an appropriate information concerning risks and notably sternotomy. Postoperative complications seem to be more common than in classical thyroid surgery, but retrograde inferior laryngeal nerve dissection and downward dissection of the posterior side of the lobe enable good control of critical structures and reduce the rate of complications. The procedure requires optimal cooperation between all those involved, on the medical, radiological, anesthesiological and surgical levels. Disclosure of interest The authors declare that they have no competing interest. References
Fig. 5. Finger ascension of plunging party of goiter along the thyroid capsule.
rarely needed. In the vast majority of cases of tracheomalacia, symptoms were present preoperatively, in the form of stridor with symmetrically mobile vocal folds. Postoperative respiratory distress or stridor in preoperatively asymptomatic patients suggests intraoperative recurrent nerve injury, requiring emergency flexible endoscopy [31,32]. The risk of recurrent nerve injury is greater than in classical thyroid surgery, at 2–10% [21,30,35,39,40]. The nerve may get stretched during extraction, especially on the right, or get sectioned if it is adherent to the goiter. The risk is greatly increased by sternotomy, with 3–8% definitive recurrent nerve palsy [10,29,30,40,41]. The risk of parathyroid gland lesion is also greater than in classical thyroid surgery. The glands can be hard to locate, especially the inferior parathyroid (P3), which often adheres to the deep side of the goiter, very low at the cervico-thoracic junction. It is easily injured during extraction and subsequent dissection if vessel ligation is not performed in contact with the capsule. Immediate hypoparathyroidism is very common in bilateral procedures, but generally resolves quickly. Persistent hypoparathyroidism is more frequent than in surgery for strictly cervical goiter, with a rate of around 2.8% [42,43]. The risk is greater in revision surgery, where dissection is more difficult, making parathyroid vascularization more difficult to conserve. Postoperative PTH assay guides requirements for calcium or vitamin D supplementation [44,45].
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Assessment and management of cervico-mediastinal goiter E. Brenet ∗ , X. Dubernard , J.C. Mérol , M.A. Louges , M. Labrousse , M. Makeieff Département d’otorhinolaryngologie et chirurgie cervico-faciale, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
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Keywords: Goiter Sternotomy Retrograde dissection of the inferior laryngeal nerve
a b s t r a c t Cervico-mediastinal goiter is a particular entity from the point of view of thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and perform a painstaking preoperative work-up, so as to draw up fully-fledged plan. CT is now indispensable, to anticipate risks and determine whether sternotomy is needed. Surgery seems to induce more postoperative complications than in conventional surgery, although they can be reduced by retrograde dissection of the inferior laryngeal nerve and downward dissection of the posterior side of the lobe to optimize control of adjacent structures. This surgery requires optimal teamwork between all of the specialties involved in patient management: medical, radiological, anesthesiological and surgical. © 2017 Elsevier Masson SAS. All rights reserved.
1. Introduction Thyroidectomy is a well-codified procedure under normal circumstances, but the presence of substernal goiter (SSG) requires the surgeon to adapt technique intraoperatively [1,2]. SSG is defined clinically and/or radiologically as extension of the thyroid below the sternal fork when the patient is in supine position [3]. This is an anatomic definition and does not help the surgeon anticipate intraoperative problems. It may not be possible to palpate the inferior end of the goiter in the lower part of the neck without aggravating the difficulty of surgery. The scope of difficult thyroidectomy has recently been updated to include SSG [4], covering factors liable to cause surgical problems: • topographic: cervico-thoracic and ectopic intrathoracic goiter; • technical: auto-immune thyroiditis, locally advanced cancer, recurrence; • anatomic: “non-recurrent recurrent nerve”, preoperative recurrent nerve palsy. We thus define SSG as a thyroid gland with inferior prolongation necessitating specific extraction maneuvers liable to increase surgical risk. Two entities can be distinguished in SSG: cervico-thoracic goiter (CTG) and intrathoracic goiter (ITG), the latter featuring the development of ectopic thoracic thyroid tissue, with no continuity with
the cervical tissue. CTG shows exclusively thyroid vascularization, whereas ITC is not only more rare (< 1% of goiters) but also shows specifically thoracic vascularization (internal thoracic artery, aorta, etc.) [4], and thus comes within the field of thoracic surgery, with specific approaches [5]. 2. Pathophysiology Causes leading to goiter are multiple: genetic, toxic (smoking), natural (manioc) and environmental (iodine deficiency), autoimmune thyroid disease and cancerous, hormonal or infiltrating pathology [6]. Thoracic extension in CTG is progressive, toward regions of lower anatomic resistance behind and forward of the supra-aortic vessels. Anterior extension is the most frequent at about 75% of CTGs [4]. It is more rapidly compressive, hindered in its inferior development by the brachiocephalic artery. CTGs with posterior development can become quite large, without clinical impact or symptoms, as there is a large space posterior to the brachiocephalic artery. Leftward development of posterior goiter is blocked inferiorly by the aortic cross and laterally by the common carotid and subclavian arteries (Fig. 1), and extension is rather inter-tracheoesophageal or retro-esophageal, giving rise to a typical scarf aspect. This form is rare, but not altogether exceptional at about 3% of cases; it makes surgery especially complex. 3. Preoperative work-up [7] 3.1. Clinical assessment
∗ Corresponding author. 6, rue de l’Ecu, 51100 Reims, France. E-mail address: [email protected] (E. Brenet).
The most common symptom is dyspnea, found in 59% of cases: in 39% as a feeling of being short of breath and in 20% as positional
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Fig. 3. Contrast-enhanced cervico-thoracic CT, axial slice: large substernal goiter extending under the aortic arch.
Fig. 1. Cervico-thoracic region: goiter extension, paths (right and left arrows). Right: passage behind brachiocephalic artery (white star). Left: downward extension blocked by aortic arch (black star) and common carotid artery (white hexagon), therefore passing behind the esophagus or trachea.
dysthyroidism, which is a risk factor for surgical difficulties [4]. Thyroglobulin assay is not recommended. Calcitonin assay is performed preoperatively in case of suspected risk of thyroid medullary carcinoma [7]; false positives underlying calcitonin elevation comprise Hashimoto thyroiditis, chronic kidney failure, or hypercalcemia [14,15]. 3.3. Radiologic work-up
Fig. 2. Cervico-thoracic goiter, patient in operative position: obese short-necked patient; Note superficial venous circulation, indicating superior vena cava syndrome.
dyspnea. The second most frequent symptom is dysphagia, found in 43% of cases, mainly concerning solids, and sometimes associated with pharyngolaryngeal reflux [8]. Dysphonia is less frequent, but requires preoperative indirect laryngoscopy to assess vocalfold mobility; this examination is especially important in revision surgery or if the patient has already undergone cervico-thoracic surgery [9]. Goiter volume is assessed on the WHO classification. Contrastenhanced cervico-thoracic CT scan is recommended to screen for substernal extension, if the goiter is not entirely palpable, notably in patients who are obese, have a short neck or present kyphoscoliosis [10]. Superior vena cava syndrome is found directly in 5–9% of cases [8,11] (Fig. 2), or may be revealed by Pemberton’s maneuver, with the face turning crimson when the patient holds his or her arms above the head for a few minutes [12,13]. 3.2. Biological work-up Assays of TSH, thyroid hormones and TSH-receptor, thyroperoxidase and thyroglobulin antibodies reveal autoimmune
First-line imaging is by ultrasound, even in clinically manifest goiter [16]. Fine-needle aspiration of ultrasound-suspect nodules follows the indications for management of a normal-sized thyroid [17]. An intracavity probe assesses substernal extension. Contrast-enhanced CT scan is the gold-standard for cervicomediastinal exploration. Vascular exploration focuses in detail on the relations between the goiter and the aortic arch, common carotid artery, brachiocephalic artery, subclavian artery and the two brachiocephalic veins. Goiter descending below the aortic arch is difficult to extract and thus entails a risk of sternotomy [18] (Fig. 3). Exploration screens for a retro-esophageal subclavian artery that may be induce dysphagia lusoria and is systematically associated with a “nonrecurrent right recurrent” nerve, originating from the vagus nerve in the upper neck, which is a major surgical pitfall [19]. Digestive exploration screens for tracheo-esophageal dissociation in case of “scarf goiter” and also for radiologic tracheal compression, found in 35–97% of cases, depending on the report [8,20]. Surgery is indicated for ≥ 35% tracheal stenosis and achieves significant alleviation of dyspnea in 95–98% of cases. In < 35% stenosis, surgery is indicated only in case of clinical symptoms or in young patients to prevent any potentially harmful medium-to-long-term progression [20]. Iodine-131 scintigraphy is recommended only if TSH levels are below normal. 4. Revelation and surgical indications Age is the first parameter to consider. Asymptomatic goiter in a patient of advanced physiological age is not in itself an indication for surgery. In young patients, on the other hand, the risk of the goiter growing and becoming compressive or malignant justify surgery even in the absence of symptoms [21]. In case of symptom onset, a complete assessment work-up is mandatory. Acute respiratory distress, dysphagia or signs of vascular compression provide brutal revelation and require rapid and difficult treatment. Such situations may arise with an episode of hyperthyroidism, hematocele or oncologic degeneration (e.g., anaplasia). It is estimated that 1–3% of patients with untreated plunging goiter
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die from respiratory causes, whence the need to operate on young asymptomatic patients [22,23]. CT assessment is essential, to identify the goiter and its vascular relations and detect any invasion of the visceral axis that might lead to tumoral transformation, such as anaplasia, often contraindicating surgery [10]. In patients with history of surgery, scar tissue in the thyroid fossa promotes development of the goiter toward the cervicothoracic isthmus on remaining or overlooked thyroid tissue [1,17,23]. Finally, it is important during the work-up to identify any factors predictive of need for sternotomy. Clinically, SSG of more than 160 months’ progression is an important risk factor. Radiologically, high thyroid tissue density, retrovascular goiter location and extension below the carina increase the risk of sternotomy, with relative risk of 47.3, 10.5 and 20.5, respectively [24]. Other sternotomy risk factors have been reported: extension below the aortic arch (PPV, 54%; NPV, 97%), predominantly right-side location (PPV, 21%; NPV, 95%), or retrotracheal location [25]. Surgical indications should systematically be discussed in the multidisciplinary team, taking account of the opinions of the patient’s physician, the patient, the endocrinologist, the anesthesiologist and the cervical and thoracic surgeons [18]. 4.1. Preoperative thoracic consultation and patient information Sternotomy is rare, at 1% to 3% of cases [4,18,26], but needs to be anticipated. A preoperative consultation with the thoracic surgeon is recommended in case of history of radiation therapy or neck surgery, suspected malignancy with extra-thyroidal extension, extension below the aortic arch or to the posterior mediastinum, or ectopic mediastinal goiter without connection to the cervical goiter [7]. The consultation allows the patient to be informed of the possibility, modalities and consequences of sternotomy [18,27]. 5. Cervico-thoracic goiter surgery Cervico-thoracic goiter surgery is complex and can only be performed in reference centers with experienced surgical and anesthesiological teams [28,29]. 5.1. Intubation Intubation is performed by an experienced anesthesiologist in difficult indications, although SSG entails no specific difficulties of intubation [30]. The surgeon should be on hand during induction, and teamwork with the anesthesiologist should be optimal. In case of foreseeable difficulties (with pharyngolaryngeal involvement or obesity), intubation should be performed with the patient awake, under flexible endoscopy [31]. A probe is positioned to monitor recurrent nerve activity [32]. 5.2. Surgery The objective is to extract the entire goiter through a cervical approach, with optimal control of large vessels. Cervico-thoracic goiter surgery differs from conventional thyroid surgery in two ways: it includes location and retrograde dissection of the inferior laryngeal nerve and raising the goiter to the cervical region through the anterior part of the superior thoracic orifice. The veins in particular are exposed: notably, the brachiocephalic vein in anterior goiter and the azygos vein in deep goiter. Controlling vascular problems before raising the goiter can be difficult and chancy and may require emergency sternotomy to enable access [33]. It is therefore important for the surgeon to be precisely
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aware of vessel size, prolongations and relations to large vessels [33,34]. The patient is positioned with the arm along the body and neck in hyperextension, with a support under the shoulders if necessary. A medial cervical incision of a length corresponding to the goiter is made along the sternal manubrium. When the cervical white line is found, it is incised from the hyoid bone down to the sternal manubrium. The superficial and deep infrahyoid muscles are pulled aside by retractors after release from the thyroid capsule underneath and may be sectioned if exposure requires. Dissection begins on the less plunging side, performing the first lobotomy then freeing the anterior and lateral side of the trachea by sectioning Grüber’s ligament to the contralateral side. Dissection then continues downward, releasing the anterior part of the goiter from its tracheal attachments, allowing a second step, which is to raise the thoracic prolongation of the goiter. The superior end of the lobe is exposed and the superior thyroid artery is ligated, taking care not to involve the superior laryngeal nerve, which sometimes descends to a greater or lesser extent on the superior end of the lobe and can easily be injured if it becomes detached. A traction wire is positioned on the superior end of the lobe. Dissecting the superior end provides access to the posterior retrothyroid plane and lateral side of the lobe. The inferior laryngeal nerve is then located, moving downward from its entry point in the larynx. This retrograde dissection enables the nerve to be located and dissected when it is not exposed laterally by inclining the lobe. Goiters may be too large and hard for a conventional technique without risk of recurrent nerve lesion [2,10,35]. The inferior laryngeal nerve is located under the edge of the cricoid cartilage and just behind the inferior horn of the thyroid cartilage. The cricopharyngeal muscle, covering the cricoid is followed down to its inferior edge, from which the inferior laryngeal nerve has to be explored downward. The lobe, held down by a retractor, delineates a triangular anatomic area comprising the inferior edge of the cricopharyngeal muscle above, the trachea within and the esophagus below. This stage of dissection is closest to the nerve, adherent to the thyroid capsule and hemostasis should, if possible, be avoided until the inferior laryngeal nerve has been identified. Once identification has been confirmed by neurostimulation, the nerve is followed downward. This retrograde dissection significantly reduces the risk of transient or permanent inferior laryngeal nerve palsy in goiter surgery [2]. The thyrotracheal attachments are then sectioned and the inferior thyroid artery is located, ligated and sectioned (Fig. 4). The plunging part of the goiter is then lifted by the index finger, which is placed on the capsule, and slid along the posterolateral side of the lobe down to the inferior end then up over the anterior side until a resistance, indicating the inferior thyroid veins, is encountered (Fig. 5). The lobe is raised and the veins are controlled after “delivering” the lobe. Bleeding occurring before extraction can hinder control [36] and this is when sternotomy may become necessary. Drains may not be necessary and do not reduce compressive cervical hematoma or provide faster detection [37], but are used with obese patients or in case of kyphoscoliosis, where clinical surveillance is less reliable [38]. Closure is then performed in the classical way.
6. Postoperative course Surveillance should be close during the first 24 hours. Extubation is performed in the operating room, in presence of the surgeon. Tracheomalacia secondary to cartilage ring compression by the goiter is very rare. Techniques such as tracheal resection-anastomosis, endotracheal implant or tracheopexy are
Please cite this article in press as: Brenet E, et al. Assessment and management of cervico-mediastinal goiter. European Annals of Otorhinolaryngology, Head and Neck diseases (2017), http://dx.doi.org/10.1016/j.anorl.2017.06.001
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Thyroid hormone replacement is initiated on the day after surgery, at 1.4–1.6 g/kg/day. TSH assay at 4–6 weeks guides replacement dosage. 7. Conclusion
Fig. 4. Release of thyroid lobe after retrograde inferior laryngeal nerve dissection (arrow) and control of inferior thyroid artery (star).
Cervico-thoracic goiter is a particular entity in thyroid surgery. Its volume, hardness and intrathoracic extension require the surgeon to adapt technique and above all, perform thorough preoperative assessment so as to draw up a full intervention plan. CT is now indispensable, enabling the patient to be given clear an appropriate information concerning risks and notably sternotomy. Postoperative complications seem to be more common than in classical thyroid surgery, but retrograde inferior laryngeal nerve dissection and downward dissection of the posterior side of the lobe enable good control of critical structures and reduce the rate of complications. The procedure requires optimal cooperation between all those involved, on the medical, radiological, anesthesiological and surgical levels. Disclosure of interest The authors declare that they have no competing interest. References
Fig. 5. Finger ascension of plunging party of goiter along the thyroid capsule.
rarely needed. In the vast majority of cases of tracheomalacia, symptoms were present preoperatively, in the form of stridor with symmetrically mobile vocal folds. Postoperative respiratory distress or stridor in preoperatively asymptomatic patients suggests intraoperative recurrent nerve injury, requiring emergency flexible endoscopy [31,32]. The risk of recurrent nerve injury is greater than in classical thyroid surgery, at 2–10% [21,30,35,39,40]. The nerve may get stretched during extraction, especially on the right, or get sectioned if it is adherent to the goiter. The risk is greatly increased by sternotomy, with 3–8% definitive recurrent nerve palsy [10,29,30,40,41]. The risk of parathyroid gland lesion is also greater than in classical thyroid surgery. The glands can be hard to locate, especially the inferior parathyroid (P3), which often adheres to the deep side of the goiter, very low at the cervico-thoracic junction. It is easily injured during extraction and subsequent dissection if vessel ligation is not performed in contact with the capsule. Immediate hypoparathyroidism is very common in bilateral procedures, but generally resolves quickly. Persistent hypoparathyroidism is more frequent than in surgery for strictly cervical goiter, with a rate of around 2.8% [42,43]. The risk is greater in revision surgery, where dissection is more difficult, making parathyroid vascularization more difficult to conserve. Postoperative PTH assay guides requirements for calcium or vitamin D supplementation [44,45].
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