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© 2004 European Association of Cardio-Thoracic Surgery
Acute respiratory failure and tracheal obstruction in patients with posterior giant mediastinal (intrathoracic) goiter
a Department of Chest Diseases, Akdeniz University Medical Faculty, Antalya, Turkey
* Corresponding author. Address: Meltem Mahallesi, Kartal Sitesi, C Blok, Daire 28, Antalya, Turkey. Tel.: +90-54-36-43-5517; fax: +90-242-22-744-90 Received May 21, 2003; received in revised form October 17, 2003; accepted November 11, 2003
The extension of a thyroid goiter into the mediastinum, commonly known as a substernal goiter, is commonly located in the anterior mediastinum. Substernal enlargement of a goiter can cause compression of several mediastinal structures including the trachea. Tracheal compression may rarely lead to acute respiratory failure. We present a patient with tracheal compression and respiratory failure due to a posterior mediastinal goiter in the light of the literature.
Key Words: Mediastinal mass; Intrathoracic goiter; Respiratory failure
A goiter, situated in the thoracic cavity is usually referred to as intrathoracic goiter. The urgent indication for resection of a goiter is compression of the adjacent organs; the trachea, the esophagus and the superior vena cava. Tracheal compression and severe respiratory compromise are the most common findings encountered in 45% of patients with intrathoracic goiter [1]. We present a patient with hyperthyroidism, who had tracheal compression and respiratory failure due to a posterior mediastinal goiter and required emergency intubation and respiratory support.
A 76 year old woman was admitted to the hospital with complaints of dry cough, sore throat and dyspnea. After admission she had progressive worsening in her respiratory status within hours and required immediate tracheal intubation and respiratory support. On physical examination she had an irregular pulse rate of 80 beats/min. The lobes of the thyroid gland were diffusely palpable and nodular. Laboratory findings were as follows: Hct, 30; Hb, 9.8 g/dl; WBC,13.700/mm3, CRP,10 mg/dl. Thyroid function tests revealed hyperthyroidism; free T3, 4.79pg/ml (1.8–4.2pg/ml), free T4, 3.94pg/ml (0.8–1.9pg/ml); and TSH, <0.002IU/ml (0.4–4). Chest roentgenogram showed a large mass (goiter) in the upper right thorax (Fig. 1). Tomograms of this area revealed a solid mass, situated in the posterior mediastinum and compressing the trachea. (Fig. 2). The patient had a lower respiratory tract infection and was treated with nonspecific antibiotic therapy for 10 days and then consulted to thoracic surgery.
Upon making collar incision on the neck we saw thyroid tissue in multinodular type descending from thoracic inlet to posterior mediastinum. We thought it was impossible to remove the mass by performing total thyroidectomy, so we decided on a posterolateral thoracotomy. We performed an operation fifth intercostales spaces. A capsulated soft mass (15x10x5 cm) containing colloid which was pressing the right bronchus to the right side was found in the posterior mediastinum. We explorated the mass and saw that it was filling 60% of the right hemithorax, and caused atelectasia in upper and middle lobes of the lung. We deflated the right lung, opened mediastinal pleura with digital dissection and the rest of the mass was then enucleated. We closed mediastinal pleura after being sure that the atelectatic lung was expanding. Histological examination of both resected specimens confirmed colloidal goiter. After 2 months of follow up the patient was well and she was able to perform her normal daily activities.
Mediastinal goiter is most frequently situated in the anterior mediastinum. Posterior mediastinal goiters constitute 10–15% of all intrathoracic goiters [2]. Respiratory infections and hemorrhage into cystic lesions are two of the reasons for sudden worsening of respiratory status [3,4]. There was a history of respiratory infection and hemorrhagic areas within the resected goiter in our patient. Shaha et al. reported that in their series 25% of the patients presented with acute airway distress and 10% required emergency airway intubation [5]. Our patient was intubated right after admission to the emergency department. She remained intubated for 4 days and was subjected to elective surgery afterwards. The majority of patients with retrosternal goiter develop symptoms include neck mass, shortness of breath, hoarseness, v. cava obstruction, dysphagia and pericardial effusion [3,6]. In one report, 20% of the patients had manifestations of hyperthyroidism [1]. Our patient had a large posterior intrathoracic goiter and most of the symptoms were due to compression of the trachea and right main bronchus. She had clinical manifestations of hyperthyroidism, confirmed by thyroid function tests. Although mediastinal goiter is usually thought of as an anterior mediastinal lesion, in one very selective surgical series as many as 25% of them were located in the posterior mediastinum. Intrathoracic goiter should be treated surgically for several reasons: (1) it does not respond to medical treatment; (2) in order to establish a tissue diagnosis when malignancy is suspected and for threatening potential malignancy; and (3) for preventing potential acute airway compromise [1–3,5,6]. The giant intrathoracic mass challenges the surgeon in a high-risk operation and serious technical difficulties such as a major vascular lesion and diffuse blood loss cause life threatening intraoperative complications [4]. Complications associated with the surgical removal of a substernal goiter are relatively rare. These are hematoma, recurrent laryngeal nerve injury, pneumothorax, pneumonia, tracheomalacia, postoperative pleural effusion, transient hypocalcemia, cervical plexopathy [6]. The mass in our patient was removed by an appropiate surgical tecnique without complications despite technical difficulties. In conclusion, usually despite its benign nature, the goiter may cause a life threatening compression of the respiratory tract and serious dislocation of the mediastinal vessels. Differential diagnosis must be made from other mediastinal masses. doi:10.1016/S1569-9293(03)00270-6
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Abstract
1. Introduction
