Background: Retrosternal goiter surgery is a technically challenging procedure. Selecting the appropriate surgical approach is critical in preventing surgical and anesthesia complications.
Objectives: This retrospective clinical study aimed to investigate the role of thyroid volume and weight in the development of retrosternal goiter and the importance of special anesthesia management in patients with retrosternal goiter, which is a potentially difficult airway candidate.
Methods: Retrosternal goiter was detected in 125 patients through ultrasonography. Patients were divided into cervical surgery (CA) and sternotomy (ECA) groups. Volumetric measurements were performed ultrasonographically. Patients' demographics, preoperative thyroid ultrasonography features, American Society of Anesthesiologists (ASA) classifications, Mallampati classifications, intubation characteristics, perioperative and postoperative patient data, and postoperative thyroid specimen weights were recorded.
Results: A total of 106 patients (32 male and 74 female) were operated on for bilateral total thyroidectomy. Total thyroidectomy was performed with CA in 98 (92.5%) patients and with ECA in 8 (7.5%) patients. Malignancy was detected in 4 (3%) of 106 operated cases. All of the malignant cases were seen in patients with a cervical approach. When the volumetric measurements of both groups were compared, the volume values were significantly higher in the ECA group (P=0.032).
67 patients were ASA I and 39 patients were ASA II. 64 patients were defined as Mallampati Class I, 36 patients as Mallampati Class II, and 6 patients as Mallampati Class III. Intubation was performed on the third attempt for 5 patients and 8 patients with Mallampati I and Mallampati II, respectively. The rate of difficult intubation was statistically significant in the ECA group (P=0.019).
Conclusion: Predicting ECA requirement in the preoperative period is closely related to the preoperative volumetric analysis of the thyroid gland with three-dimensional ultrasonography. In addition, since anesthesia management is difficult in patients who need ECA, volumetric analysis has become even more critical.
Khan MN, Golio E, Owen R, Woo Park RC, Yao M, Miles BA. Retrosternal goiter: 30-day morbidity and mortality in
the transcervical and transthoracic approaches.
Otolaryngol Head Neck Surg. 2016;155(4) :568-74. doi: 10.1177/0194599816649583. [PubMed: 27221572].
El Hammoumi M, El Oueriachi F, Arsalane A, Kaibiri EH. Surgical management of retrosternal goitre: experience of a Morrocan centre. Acta Otorrinolaringol Esp. 2014;65(3):177-82. doi: 10.1016/j.otorri.2013.12.009. [PubMed: 24726024].
Coskun A, Yildirim M, Erkan N. Substernal goiter: when is a sternotomy required? Int Surg. 2014;99(4):419-425. doi: 10.9738/INTSURG-D-14-00041.1. [PubMed: 25058777].
Landerholm K, Järhult J. Should a symptomatic
retrosternal goitre be left untreated? A prospective single-centre study. Scand J Surg. 2015;104(2):92-95. doi: 10.1177/1457496914523411. [PubMed: 24759378].
Sahbaz NA, Tutal F, Aksakal N, Acar S, Aksu KI, Barbaros U, et al. Cancer frequency in retrosternal goiter. Am Surg. 2017;83(12):1390-3. [PubMed: 29336760].
de Perrot M, Fadel E, Mercier O, Farhamand P, Fabre D, Mussot S, et al. Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg. 2007;55(1):39-43. doi: 10.1055/s-2006-924440. [PubMed: 17285472].
Cohen JP. Substernal goiters and sternotomy. Laryngoscope. 2009;119(4):683-8. doi: 10.1002/lary.20102.
Hanson MA, Shaha AR, Wu JX. Surgical approach to the substernal goiter. Best Pract Res Clin Endocrinol Metab. 2019;33(4):1-20. doi: 10.1016/j.beem.2019.101312. [PubMed: 31477522]
Ozpolat B, Buyukasık O, Osmanoglu G, Dogan S, Kargıcı H. Is cervicotomy enough for removal of retrosternal goiters? Turk J Med. 2008;38(6): 561-5.
Mercante G, Gabrielli E, Pedroni C, Formisano D, Bertolini L, Nicoli F, et al. CT cross-sectional imaging classification system for substernal goiter based on risk factorsfor an extra cervical surgica lapproach. Head Neck. 2011;33(6):792-9. doi: 10.1002/hed.21539. [PubMed: 20737483].
Fathalla A, Ahmed B. Surgical approaches to retrosternal goiter, when sternotomy ıs mandatory? national cancer ınstitute experience (ncı), cairo university, Egypt. J Cancer Ther. 2016;7(4):311-8. doi: 10.4236/jct.2016.74033.
Raffaelli M, De Crea C, Ronti S, Bellantone R, Lombardi CP. Substernal goiters: Incidence, surgical approach, and complications in a tertiary care referral center. Head Neck. 2011;33(10): 1420-5. doi: 10.1002/hed.21617. [PubMed: 21928414].
Cichon S, Anielski R, Konturek A, Baczynski M,
Cichon W, Orlicki P.Surgical management of mediastinal
goiter: risk factors for sternotomy. Langenbecks Arch
Surg. 2008;393(5):751-7. doi: 10.1007/s00423-008-0338-y. [PubMed: 18488246].
Bartın MK, Yılmaz EM, Arslan H, Tekeli AE, Karataş S. A case of primary hydatidcyst in the thyroid gland. Ulus Cerrahi Derg. 2014;31(2):94-5. doi: 10.5152/UCD.2014.2668. [PubMed: 26170748]
Bartın MK,. Effects of fine needle aspiration biopsy of
thyroid nodules on thyroid hormone sand thyroglobulin. Endokrinolojide Diyalog Derg. 2016, 13(1): 29-32.
Tan PCS, Esa N. Anaesthesia for massive retrosternal goiter with severe intrathoracic tracheal narrowing: the challenges imposed- A case report. Korean J Anesthesiol. 2012;62(5):474-8. doi: 10.4097/kjae.2012.62.5.474. [PubMed: 22679546].
Loftus PA, Ow TJ, Siegel B, Tassler AB, Smith RV, Schiff BA.
Risk factors for perioperative airway difficulty and
evaluation of intubation approaches among patients with benign goiter. Ann Otol Rhinol Laryngol. 2014;123(4):279-85. doi: 10.1177/0003489414524171. [PubMed: 24595624].
Dempsey GA, Snell JA, Coathup R, Jones TM. Anaesthesia for massive retrosternal thyroid ectomy in a tertiary
referral centre.Br J Anaesth. 2013;111(4):594-9. doi: 10.1093/bja/aet151. [PubMed: 23690528].
Chen AY, Bernet VJ, Carty SE, Davies TF, Ganly I, Inabnet WB, Shaha AR: American thyroid association statement on optimal surgical management of goiter. Thyroid. 2014;24(2):181-9. doi: 10.1089/thy.2013.0291. [PubMed: 24295043].