Presentation on theme: "Management of substernal goiter UCH KH Tse. Clinical scenario 70/F Asymptomatic. Refer for your expert opinion."— Presentation transcript:
Management of substernal goiter UCH KH Tse
Clinical scenario 70/F Asymptomatic. Refer for your expert opinion.
Questions What is the diagnosis ? How do you manage ?
Introduction SSG First described by Haller in Account for 10-15% of all the mediastinal mass. SSG / All thyroidectomy = % Madjar Chest 1995
Definition Confused. 1.Decend inferior to the thoracic inlet. Katlic et al Am J Surg >50% thyroid mass inside the thorax. Wax et al J Otolaryngol 1992 Arici et al Int Surg Goitres extend to 4th thoracic vertebra. Lindskog and Goldenberg JAMA 1957
Anatomy SSG classified into two groups. 1.Truly intrathoracic or aberrant goiter (1%). Congenital Blood supply derived from the intrathoracic vessel entirely. No connection to the cervical thyroid gland. Lahey & Swinton et al 1934
Anatomy 2. Arises in the cervical thyroid gland Acquired. Decends along a fascial plane through the thoracic inlet to the mediastinum. Lahey & Swinton et al 1934
Symptomatology Neck mass, SOB, dysphagia. 5-50% can be asymptomatic on presentation. Katlic MR Am J Surg 1985 Prolong course of symptoms. From 2 weeks to 20 years with symptoms before referral. Mean = 31 months.
Rationale for operation 1. SSG is progressive, can result in sudden airway obstruction. Singh B Am J Otolaryngol Inaccessible to, inaccurate, and dangerous biopsy. Rietz KA Acta Chir Scand Long history MNG does not preclude malignancy, hyperfunction or complication. Malignancy in 7-17% Sanders Arch Surg 1992 Torre G Am Surg 1995
Rationale for operation 4.No effective alternative treatment. I131? T4? Allo MD Surgery Less operative complication in the asymptomatic patients. Para-Menbrives et al Internat Surg 2003 The consensus is that substernal goiter is best managed surgically. Katlic MR Am J Surg 1985
Investigation CT neck and thorax is the most valuable. Netterville et tal Laryngoscope 1998 Sanders LE Arch Surg Outline the extent of thyromegaly. 2.Differentiate the origin of the goiter. 3.Measure the degree of narrowing of the trachea.
The operation 1.Head up, neck well extended. 2.Wider and lower incision. 3.Division of the strap muscles. 4.Control cervical blood supply first. 5.Excise the opposite lobe first, to provide more room in the neck. Wheeler M.H. et al BJS 1999 Sternotomy rate % Michel LA Br J Surg 1988
The operation No Progress ManubrinectomyClaviclectomy Median sternotomy/ Limited sternotomy
The operation Other indications for sternotomy / thoracotomy 1.Intra thoracic goitre / ectopic goitre. 2.Vasoagressive signs. 3.Retroesophageal goiters. 4.Suspected malignancy, mediastinal lymphadenectomy. 5.After a prior cervical thyroidectomy, with intra-thoracic recurrent.
Our study Retrospective study From Jan 2000 to Dec cases of thyroidectomy. 24 (8.4%) were SSG M:F = 5:19 Mean age 60.1+/-15.5 ( )
Symptoms in patients with substernal goitre Symptoms & signs Number(%) SOB (including 3 cases of acute airway obstruction) 8(33.3) Neck discomfort 1(4.2) Dysphagia 1(4.2) Hoarseness 1(4.2) Asymptomatic 13(54.2) Duration of symptoms months, mean /- 47.5