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Figure 4 coronal). Result of her thyroid function test showed hiperthyroid profile with serum thyroid stimulating hormone (TSH) of 0.001 uUI/ml, T3 of 15.4 ng/ml, ...
A.Emre, et al. Surg Chron 2017; 22(1): 18-20.

Giant posterior mediastinal goiter managed by cervical collar incision: A case report Arif Emre1*, Selami Ilgaz Kayilioglu2, Tolga Dinç2, Nursel Yurttutan3, Ilhami Taner Kale1, Mehmet Sertkaya1 1

Kahramanmaraş Sütçü Imam University School of Medicine, Department of General Surgery, Kahramanmaraş/TURKEY Ankara Numune Training and Research Hospital, Department of General Surgery, Ankara/ TURKEY 3 Kahramanmaraş Sütçü Imam University School of Medicine, Department of General Radiology, Kahramanmaraş/TURKEY 2

Abstract Retrosternal goiters are mostly located in the anterior mediastinum, acording to literature, less often in the posterior mediastinum are located. Posterior mediastinal goiters can be removed to transcervical approach just as anterior mediastinal goiters. In spite of anterior localized goiters, surgical resection of the posterior mediastinal goiters have more complicated process and more frequently require sternotomy, thoracoscopy or thoracotomy approach. Extratranscervical approach when compared with cervical approach it has serious complications which can lead to higher morbidity and mortality. Those complications are variable and each one is specific to the patient. Here in we present a giant posterior mediastinal goiter case which grew into posterior mediastine extending to the azygous vein. Most of the retrosternal goitres transthoracic approach can be requirement, depending on the size and the elongation. In contrast, retrosternal goitres in some appropriate cases can remove successfully with standard cervical collar incision. Key Words: Giant goiter, retrosternal posterior mediastinal goiter, collar incision.

Introduction The extention of a thyroid gland in the neck into the mediastinum behind the sternum is defined as substernal goiter. Its frecuency range from 0.02 % to 30.4 % partly due to the different decriptions [1]. Degree of difficulty and complication rates of surgeries which performed because of retrosternal goitres compared with the normal localization is high. Altough, most of them can remove by means of transcervical approach, rest of them requires extracervical approach such as sternotomy, thoracoscopy or thoracotomy. In this paper we presentate the management of a patient with giant posterior mediastinal goiter who underwent surgery via cervical collar incision. Case Presentation A 58-year-old female patient was admitted to our general surgery departmant with headache, tremor, palpitation, fatigue and dyspnea during 35 years. She were receiving medical treatment due to bronchial asthma the last 10 years. A giant thyroid goiter located both in normal cervical position and the mediastinum was discovered result of her physical examinations, labaratory investigations, including X-Ray (Figure 1), scintigraphy (Figure 2) and computed tomography (CT) of the neck and chest demonstration. CT showed a goiter which grew into the right posterior mediastinum associated with the right thyroid. The right goiter (mediastinal part of the righ thyroid gland) was extended into the thorax as line of the azygous vein and aortic arch between dorsal part of the tracheal bifurcatio, the spine, the trachea and eusophagus (Figure 3a-d axial, Figure 4 coronal). Result of her thyroid function test showed hiperthyroid profile with serum thyroid stimulating

hormone (TSH) of 0.001 uUI/ml, T3 of 15.4 ng/ml, free T4 of 6.27ng/dl.

Figure 1: Thoracic x ray.

Figure 2: A right-sided mediastinal mass in Scintigraphy scan.

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A.Emre, et al. Surg Chron 2017; 22(1): 18-20.

A decision was made to remove right thyroid lobe which grew into the right posterior mediastinum and left thyroid lobectomy with preparation for a toracoscopy, if needed. A coller incision about 8 centimeters was made and firstly left thyroid lobectomy performed then rigt thyroid lobectomy with thoracic component after traction and digital mobilization attemps resulted in severing of the right lobe from the thoracic compenent at the rest of the multinodular goitre. There is no complications after the nd operation and hemovac drains were removed on the 2 postoperative day. Chest tomography is applied to determine that any remaining thyroid tissue remnants, postoperative day 3. However, remnant thyroid tissue was not observed. She recovered uneventfully and her obstrructive symptoms disappeared after the operation. She was discharged from our hospital in fourth days. On gross examination, the mass was measuring about 30x15 centimeters in size. Further histopathological examinations showed thyroid hyperplasia without malignancy.

Figure 3a-d: In thoracic computed Tomography scan, a: Thyroid gland narrows the trachea, b-c:T hyroid gland surrounds the posterior part of trachea, d: Retrosternal elngation of the thyroid gland

Figure 4: Sagittal plane of computed tomography scan (CT) of the neck and chest reveals a posterior retrosternal goiter.

Discussion The extention of a thyroid gland in the neck into the mediastinum behind the sternum is defined as substernal goiter. If the greatest diameter of the goitrous mass is

below the plane of the toracic inlet, intrathoracic goiter term can be used [1]. The majority of retrosternal goiters are attributed to be part of goiters in the neck. There is another condition which is solitary mass in the posterior mediastinum that is known as primary Intrathoracic goiter or ectopic intrathoracic goiter [2, 3]. Most of retrosternal goiters are located in the anterior mediastinum, rest of them, approximately 10-15%, are situated in the posterior mediastinum [4]. According to the location where they settled in the chest, retrosternal goiters are divided into 3 types. Type I goiters have their inferior pole over the arch of the aorta; type II goiters are those below the arch of the aorta and extending into the posterior mediastinum; type III are giant goiters that inburst into the chest or are present with superior vena cava syndrome [5]. According to this classification, our case is type I goiter. The patients have usually one or more complaints, including cervical mass, hoarseness, dysphagia, fatique, thyrotoxicosis symptoms (Palpitation, tremor, sweating etc.) In the patients with posterior mediastinal goiters can be observed the compressing symptoms of superior vena cava syndrome, especially dysphagia and dyspnea. This will also be seen in many respiratory diseases, some of the complaints of patients may lead to misdiagnosis, such as bronchitis, asthma. This situation can lead to take unjustifable medication with respiratory drugs for many years of some patients. Presented case had received treatment for 10 years with a diagnosis of bronchial asthma. Drug needs of patient significantly was reduced and obstrructive symptoms disappeared after the operation. This case has shown us that in a patient with dysphagia complaint or respiratory disease, her neck should be thoroughly examined and thyroid gland structure should be evaluated radiologically. Most retrosternal goiters can be removed through a cervical aproach. However, rare conditions such as cervical thyroidectomy being performed previously, invasive carsinoma, ectopic goiter likely require either a sternotomy, thoracotomy, cervicothoracic associated incision, mediastinoscopy, video-assisted thoracoscopy or robotic approach. If distal border of the mediastinal goitre below the level of the aortic arc, surgeons often need to extracervical approaches. While the sternotomy is appropriate procedure for anterior mediastinal goiters, toracoscopy and toracotomy are preferable to posterior retrosternal goiters because of major vascular neighborliness. While the standard thyroid surgery various complications may occur such as hematoma, recurrent laryngeal nerve injury, hypocalcemia due to parathyroid gland injury, in patients with retrosternal goitre. In addition to these complications annoying complications such as pneumothorax, pneumonia, pleural effusion and thoracic duct injury may occur. The proportions of these complications depending on the nature of relations with neighboring thyroid gland and the surgeon's experience varies. Fortunately, there were no complications in our case after the operation. 19

A.Emre, et al. Surg Chron 2017; 22(1): 18-20.

As a result, most of the retrosternal goitres are symptomatic and it must be removed surgically due to theirs symptoms. Most of the retrosternal goitres transthoracic approach can be requirement depending on the size and the elongation. In contrast, retrosternal goitres in some appropriate cases can remove successfully with standard cervical collar incision. This situation depend on the nature of relations with neighboring thyroid gland and the surgeon's experience varies. References 1. 2. 3.

4.

5.

Lahey FH, Swinton NW. Intra-thoracic goiter. Surg Gynecol Obstet. 1934; 59: 627-637. Wu MH, Chen KY, Liaw KY et al. Primary intrathoracic goiter. J Formos Med Assoc. 2006; 105:160-163. Pilavaki M, Kostopoulos G, Asimaki A. Imaging of ectopic intrathoracic multinodular goiter with pathologic correlation: a case report. Cases J. 2009:16; 2: 8554. Madjar S, Weissberg D. Retrosternal goiter. Chest. 1995; 108: 78-82. Wu YH, Qi YF, Tang PZ et al. The surgical method of retrosternal goitre. Chin J Otorhinolaryngol Head Neck Surg. 2006; 41: 528-531.

Author for Correspondence; Tolga Dinc Ankara Numune Training and Research Hospital/ Department of General Surgery Altindag / Ankara/ Turkey. Tel : +90 312 508 52 41 Mobile : +90 532 481 22 75 Fax : +90 312 310 34 60 e-mail : [email protected]

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