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Partial unilateral phrenic nerve paralysis caused by a large intrathoracic goitre
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JOUFWALOF MEDICINE ELSEVIER
Netherlands Journal of Medicine 48 (1996) 216-219
Brief report
Partial unilateral phrenic nerve paralysis caused by a large intrathoracic goitre L.G. van Doorn a3*,S.E. Kranendonk b a Department b Department
of Medicine, of Surgery.
Maria Hospital, Maria Hospital,
Tilburg, Tilburg,
Dr Deelenlaun Dr Deelenlaan
5, 5042 AD Tilburg. 5, 5042 AD Tilburg,
Netherlands Netherlands
Received 1 June 1995; revised 31 August 1995; accepted 5 September 1995
Abstract Intrathoracic goitres may cause a variety of symptoms caused by compression of the trachea, neural structures, blood vesselsand the oesophagus.A casehistory is presented of a patient with a recurrent goitre after subtotal thyroidectomy who displayed partial unilateral phrenic paralysis, which subsided after a second subtotal thyroidectomy. Compression of the phrenic nerve appears to be a very rare manifestation of au intrathoracic goitre and thus far has never been reported. Keywords:
Intrathoracic goitre; Phrenic nerve
1. Introduction
2. Case report
Intrathoracic goitres may cause clinical problems by their tendency to cause compression of surrounding structures such as trachea, oesophagus, jugular veins and neural structures. Of the neural structures which may become injured, the best-known examples are the recurrent laryngeal nerves and the cervical sympathetic chain, manifested by hoarseness due to vocal cord paralysis and Homer’s syndrome, respectively. These syndromes, in addition, often raise a high suspicion of malignancy of the thyroid or the
A 56-year-old woman was referred to our out patient department a few years ago for preoperative evaluation for a planned Caldwell-Luke operation due to chronic sinusitis. She was known to have diabetes mellitus type 2, diagnosed 3 years before and she underwent a subtotal bilateral thyroidectomy more than 10 years before. Apart from the symptoms caused by her chronic sinusitis she had no complaints otherwise. Physical examination revealed a large recurrent goitre, mainly left-sided, extending intrathoracically. Radiological investigation showed a slight narrowing of the trachea, which was strongly dislocated towards the right. There was also shadowing of the !owest part of the left lung suspected for plate atelectasis and elevation of the left hemidiaphragm. No radiographs from the past were available for comparison. Upon fluoroscopy the normal excursions of the
lung[1,21. We present here a patient in whom it was most likely that the partial unilateral phrenic nerve paralysis she manifested was caused by a benign intrathoracic goitre.
l
Corresponding
author.
Elsevier Science B.V. SD1
0300-2977(95)00083-6
L.G. uan Doom,
S.E. Kranendonk/Netherlmds
Journal
of Medicine
18 (1996)
216-219
217
Laboratory investigations showed a normal FIT but a blunted response of TSH after TRH administration. The patient first had her Caldwell-Luke operation and shortly thereafter was operated for her goitre. There appeared to be a large multinodular left lobe of the thyroid, with extension downwards into the thoracic cavity, which was mobilised and subsequently removed subtotally. The right lobe also appeared to be greatly enlarged but without intrathoracic extension and was also removed subtotally. The postoperative course was uneventful: vocal cord
Ventraa!
92,somh99mrc Fig. 1. Preoperative scintigram ( 99mTc) of the thyroid. X = level of lower margin of the cricoid bone; Y = level 3 cm above sternal jugulum. The scintigram of the thyroid preoperatively shows extension of the goitre at least to the lower margin of the scanning area near the upper sternal border. The exact measure of the intrathoracic extension cannot be determined.
left hemidiaphragm with breathing appeared to be strongly reduced but there was no paradoxical movement. No intrapulmonary lesions were seen. Upon bronchoscopy no intrabronchial tumour growth could be detected. Scintigraphy of the thyroid (see Fig. 1) strengthened the clinical suspicion of intrathoracic extension, especially to the left, of a large goitre.
Fig. 2. Preoperative
radiograph
of the chest.
Fig. 3. Two days postoperatively. Postoperative chest: (a) postero-anterior; (b) lateral.
radiographs
of the
218
L. G. uan Doom,
S. E. Krunendonk
/ Netherlands
Jounml
of Medicine
48 (I996I
2 16-219
function remained intact and there were no signs of postoperative hypoparathyroidism. Histological examination of the removed thyroid tissue revealed only benign dysplasia. Thyroid supplementation therapy was instituted postoperatively in order to prevent future recurrence of the goitre. The patient was seen for regular follow-up at the outpatient department and radiographs of the chest were obtained at regular intervals (see Figs. l-5). These showed a gradual improvement of the left hemidiaphragmatic elevation, first seen at 4
Fig. 5. Fifteen months after the operation; at that lime only slight relaxation of the anterior part of the left hemidiaphragm remained. Postoperative radiographs of the chest (a) postero-anterior; (b) lateral.
a
months after the thyroid operation and nearly complete (with only a slight elevation of the dorsal part) 1 year thereafter.
3. Discussion
Fig. 4. After 4 months. Postoperative postero-anterior; (b) lateral.
radiographs
of the chest: (a)
In the present case symptoms of unilateral partial phrenic paralysis resolved after subtotal resection of the apparently benign goitre. In combination with the
LG.
van Doom,
S. E. Kranendonk
/ Netherlands
exclusion of intrapulmonary lesions this strongly suggests that the phrenic nerve may also become injured by compression by an intrathoracic benign goitre. The descent of the phrenic nerve along the medial side of the anterior scale& muscle close to the clavicle bone at the level of the upper thoracic aperture may make it vulnerable especially to laterally and anteriorly extending goitres. Neural compression syndromes apart from the well-known recurrent laryngeal nerve and Homer’s syndrome seem to be extremely rare occurrences. Besides these well-known syndromes all published series of intrathoracic goitres known to us mention
Journal
of Medicine
48 (1996)
216-219
219
only a single case of a Pancoast syndrome [3]. To our knowledge this is the first published report of phrenic nerve involvement. References [l] Moumen M, Menhane M, Nawfik H, El Fares F. Les goitres plongeants. A propos de 36 cas. J Chir (Paris) 1990;10:22-26. [2] Borrely J, Grosdidier G, Wack B, Hubert J. Les goitres plongeants. &de d’une &tie de 94 cas. Ann M6d Nancy&t 1984;23:201-206. [3] Witz JP. Les goitres plongeants, les goitres thoraciques. Reflexions a propos d’une s&e int&rale de 61 observations. J Chir 1967;93:429-441.
JOUFWALOF MEDICINE ELSEVIER
Netherlands Journal of Medicine 48 (1996) 216-219
Brief report
Partial unilateral phrenic nerve paralysis caused by a large intrathoracic goitre L.G. van Doorn a3*,S.E. Kranendonk b a Department b Department
of Medicine, of Surgery.
Maria Hospital, Maria Hospital,
Tilburg, Tilburg,
Dr Deelenlaun Dr Deelenlaan
5, 5042 AD Tilburg. 5, 5042 AD Tilburg,
Netherlands Netherlands
Received 1 June 1995; revised 31 August 1995; accepted 5 September 1995
Abstract Intrathoracic goitres may cause a variety of symptoms caused by compression of the trachea, neural structures, blood vesselsand the oesophagus.A casehistory is presented of a patient with a recurrent goitre after subtotal thyroidectomy who displayed partial unilateral phrenic paralysis, which subsided after a second subtotal thyroidectomy. Compression of the phrenic nerve appears to be a very rare manifestation of au intrathoracic goitre and thus far has never been reported. Keywords:
Intrathoracic goitre; Phrenic nerve
1. Introduction
2. Case report
Intrathoracic goitres may cause clinical problems by their tendency to cause compression of surrounding structures such as trachea, oesophagus, jugular veins and neural structures. Of the neural structures which may become injured, the best-known examples are the recurrent laryngeal nerves and the cervical sympathetic chain, manifested by hoarseness due to vocal cord paralysis and Homer’s syndrome, respectively. These syndromes, in addition, often raise a high suspicion of malignancy of the thyroid or the
A 56-year-old woman was referred to our out patient department a few years ago for preoperative evaluation for a planned Caldwell-Luke operation due to chronic sinusitis. She was known to have diabetes mellitus type 2, diagnosed 3 years before and she underwent a subtotal bilateral thyroidectomy more than 10 years before. Apart from the symptoms caused by her chronic sinusitis she had no complaints otherwise. Physical examination revealed a large recurrent goitre, mainly left-sided, extending intrathoracically. Radiological investigation showed a slight narrowing of the trachea, which was strongly dislocated towards the right. There was also shadowing of the !owest part of the left lung suspected for plate atelectasis and elevation of the left hemidiaphragm. No radiographs from the past were available for comparison. Upon fluoroscopy the normal excursions of the
lung[1,21. We present here a patient in whom it was most likely that the partial unilateral phrenic nerve paralysis she manifested was caused by a benign intrathoracic goitre.
l
Corresponding
author.
Elsevier Science B.V. SD1
0300-2977(95)00083-6
L.G. uan Doom,
S.E. Kranendonk/Netherlmds
Journal
of Medicine
18 (1996)
216-219
217
Laboratory investigations showed a normal FIT but a blunted response of TSH after TRH administration. The patient first had her Caldwell-Luke operation and shortly thereafter was operated for her goitre. There appeared to be a large multinodular left lobe of the thyroid, with extension downwards into the thoracic cavity, which was mobilised and subsequently removed subtotally. The right lobe also appeared to be greatly enlarged but without intrathoracic extension and was also removed subtotally. The postoperative course was uneventful: vocal cord
Ventraa!
92,somh99mrc Fig. 1. Preoperative scintigram ( 99mTc) of the thyroid. X = level of lower margin of the cricoid bone; Y = level 3 cm above sternal jugulum. The scintigram of the thyroid preoperatively shows extension of the goitre at least to the lower margin of the scanning area near the upper sternal border. The exact measure of the intrathoracic extension cannot be determined.
left hemidiaphragm with breathing appeared to be strongly reduced but there was no paradoxical movement. No intrapulmonary lesions were seen. Upon bronchoscopy no intrabronchial tumour growth could be detected. Scintigraphy of the thyroid (see Fig. 1) strengthened the clinical suspicion of intrathoracic extension, especially to the left, of a large goitre.
Fig. 2. Preoperative
radiograph
of the chest.
Fig. 3. Two days postoperatively. Postoperative chest: (a) postero-anterior; (b) lateral.
radiographs
of the
218
L. G. uan Doom,
S. E. Krunendonk
/ Netherlands
Jounml
of Medicine
48 (I996I
2 16-219
function remained intact and there were no signs of postoperative hypoparathyroidism. Histological examination of the removed thyroid tissue revealed only benign dysplasia. Thyroid supplementation therapy was instituted postoperatively in order to prevent future recurrence of the goitre. The patient was seen for regular follow-up at the outpatient department and radiographs of the chest were obtained at regular intervals (see Figs. l-5). These showed a gradual improvement of the left hemidiaphragmatic elevation, first seen at 4
Fig. 5. Fifteen months after the operation; at that lime only slight relaxation of the anterior part of the left hemidiaphragm remained. Postoperative radiographs of the chest (a) postero-anterior; (b) lateral.
a
months after the thyroid operation and nearly complete (with only a slight elevation of the dorsal part) 1 year thereafter.
3. Discussion
Fig. 4. After 4 months. Postoperative postero-anterior; (b) lateral.
radiographs
of the chest: (a)
In the present case symptoms of unilateral partial phrenic paralysis resolved after subtotal resection of the apparently benign goitre. In combination with the
LG.
van Doom,
S. E. Kranendonk
/ Netherlands
exclusion of intrapulmonary lesions this strongly suggests that the phrenic nerve may also become injured by compression by an intrathoracic benign goitre. The descent of the phrenic nerve along the medial side of the anterior scale& muscle close to the clavicle bone at the level of the upper thoracic aperture may make it vulnerable especially to laterally and anteriorly extending goitres. Neural compression syndromes apart from the well-known recurrent laryngeal nerve and Homer’s syndrome seem to be extremely rare occurrences. Besides these well-known syndromes all published series of intrathoracic goitres known to us mention
Journal
of Medicine
48 (1996)
216-219
219
only a single case of a Pancoast syndrome [3]. To our knowledge this is the first published report of phrenic nerve involvement. References [l] Moumen M, Menhane M, Nawfik H, El Fares F. Les goitres plongeants. A propos de 36 cas. J Chir (Paris) 1990;10:22-26. [2] Borrely J, Grosdidier G, Wack B, Hubert J. Les goitres plongeants. &de d’une &tie de 94 cas. Ann M6d Nancy&t 1984;23:201-206. [3] Witz JP. Les goitres plongeants, les goitres thoraciques. Reflexions a propos d’une s&e int&rale de 61 observations. J Chir 1967;93:429-441.