Thyroidectomy for substernal usually includes goiters with minimal extension in the thoracic cavity and those that are present in the mediastinum (the area surrounding the chest cavity). As per the largest study done, the rate of sternotomy is less than 5%, the complication rates are acceptable, and the mortality is less than 1%. Thus, the outcome of substernal goiter surgery is usually good. However, the rate of complications is higher in individuals older than 60 years of age. They have a higher death rate due to postoperative complications.
Most patients may need to take thyroid hormone pills (thyroid hormone replacement) for the rest of their lives when the whole thyroid gland is removed.
In the absence of contraindications, substernal goiter should be treated with early surgery rather than having it run the risk of acute airway distress, especially in younger patients.
With careful preoperative testing and thoughtful consideration of the type of anesthesia, including the type of intubation, preparation for surgery can be optimized. In any case, the surgical team must be ready for complications from massive goiter surgery, such as:
- Airway distress
- Recurrent laryngeal nerve injury
- Temporary or sometimes permanent hypoparathyroidism (low blood calcium levels)
- Hoarseness of voice
- Inability to raise the voice
- Incomplete removal of the thyroid and complications in preserving all the critical structures beneath and around the thyroid gland are frequent events among inexperienced and occasional thyroid surgeons.
- Anesthesia-related complications
How is substernal goiter surgery performed?
Substernal goiter can be removed through a relatively straight forward collar incision in the lower neck. Rarely, a surgeon may open the sternum (chest) to remove the goiter. Opening of the chest in the surgical management of substernal goiter is rarely required. During the procedure:
- The patient is usually given general anesthesia to numb the pain and vitals are monitored throughout the procedure.
- The patient may be positioned with special pillows under the neck to tilt the head back.
- The surgeon makes a cut (incision) in the lower part of the neck just above the collar bone to determine if the mass can be removed without opening the chest. Most of the time, the surgery can be done this way. If the mass is deep inside the chest, the surgeon makes an incision along the middle of the chest bone. All goiters are then removed.
- A tube may be left in place to drain fluid and blood. It is usually removed in 1-2 days.
- The incisions are closed with stitches (sutures).
- The operation generally lasts from 2-3 hours. After surgery, the patient will stay in the recovery room for several hours. They will be monitored closely as they need to recover from the anesthesia.
- Most people take at least 15-30 days to recover. The patient may then be placed on thyroid hormone pills.
Should I be worried about the goiter?
Goiters are noncancerous enlargement of the thyroid gland. They are typically not dangerous unless cancer cells develop in the goitrous thyroid enlargement.
Most common goiters include:
- Multinodular goiter or multinodular goiter: These contain multiple nodules (small, rounded lumps or masses).
- Substernal goiter: This is an enlargement of the thyroid gland that extends underneath the breastbone and possibly in between the lungs.
Goiters may be a result of the over or underproduction of the thyroid hormone or the presence of nodules in the thyroid gland. The risk of a substernal goiter is higher in people who:
- Have certain genes or a family member with goiters.
- Have thyroid problems, such as hypothyroidism or hyperthyroidism.
Signs and symptoms:
- Frequent coughing
- Feeling that something is stuck in the throat
- Food getting stuck in the upper esophagus when swallowing (bread and meat most commonly)
- Waking up at night due to breathlessness
- Breathing problems, especially when lying down
- High-pitched sound while breathing
- If goiters are not causing any symptoms, the doctor may recommend close observation to monitor for any changes or growth over time.
- Medication to normalize abnormal thyroid hormone levels may help decrease the size of goiters.
- Surgery is typically recommended for goiters that are causing symptoms.
- A portion of the enlarged thyroid (if possible) or the entire thyroid gland may need to be removed. This surgical procedure is known as a thyroidectomy.
- When the goiter is caused by a noncancerous thyroid nodule or multiple nodules, a new technique called radiofrequency ablation (RFA) may be used. This is used to shrink the goiter and alleviate pressure-related symptoms without the need for surgery.
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Sancho JJ, Kraimps JL, Sanchez-Blanco JM, et al. Increased Mortality and Morbidity Associated With Thyroidectomy for Intrathoracic Goiters Reaching the Carina Tracheae. Arch Surg. January 2006;141(1):82-85. https://pubmed.ncbi.nlm.nih.gov/16415416/
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Common Medical Abbreviations & Terms
Doctors, pharmacists, and other health-care professionals use abbreviations, acronyms, and other terminology for instructions and information in regard to a patient's health condition, prescription drugs they are to take, or medical procedures that have been ordered. There is no approved this list of common medical abbreviations, acronyms, and terminology used by doctors and other health- care professionals. You can use this list of medical abbreviations and acronyms written by our doctors the next time you can't understand what is on your prescription package, blood test results, or medical procedure orders. Examples include:
- ANED: Alive no evidence of disease. The patient arrived in the ER alive with no evidence of disease.
- ARF: Acute renal (kidney) failure
- cap: Capsule.
- CPAP: Continuous positive airway pressure. A treatment for sleep apnea.
- DJD: Degenerative joint disease. Another term for osteoarthritis.
- DM: Diabetes mellitus. Type 1 and type 2 diabetes
- HA: Headache
- IBD: Inflammatory bowel disease. A name for two disorders of the gastrointestinal (BI) tract, Crohn's disease and ulcerative colitis
- JT: Joint
- N/V: Nausea or vomiting.
- p.o.: By mouth. From the Latin terminology per os.
- q.i.d.: Four times daily. As in taking a medicine four times daily.
- RA: Rheumatoid arthritis
- SOB: Shortness of breath.
- T: Temperature. Temperature is recorded as part of the physical examination. It is one of the "vital signs."
cryoprecipitateCryoprecipitate is a blood product containing specialized insoluble blood proteins known as coagulation factors that regulate the clotting and clot-dissolving processes. Cryoprecipitate is obtained from plasma, the fluid component of blood, and is used to treat patients with blood clotting (coagulation) disorders and to control hemorrhage during major surgery or during and after childbirth. Common side effects of cryoprecipitate include transfusion-related complications, allergic reactions, and post-transfusion bruising (purpura).
Hyperthyroidism is an excess of thyroid hormone due to an overactive thyroid gland. Symptoms can include increased heart rate, weight loss, heart palpitations, frequent bowel movements, depression, fatigue, fine or brittle hair, sleep problems, thinning skin, and irregular vaginal bleeding.
Graves' disease is the most common cause of hyperthyroidism. Many other health problems or taking excess thyroid hormone medication can cause an overactive thyroid gland. Treatment for the condition is with medication, radioactive iodine, thyroid surgery (rarely), or reducing the dose of thyroid hormone. No diet has been shown to treat hyperthyroidism or its symptoms and signs.
HypothyroidismHypothyroidism is any state in which thyroid hormone production is below normal. Normally, the rate of thyroid hormone production is controlled by the brain by the pituitary gland. Hypothyroidism is a very common condition and the symptoms of hypothyroidism are often subtle but may include constipation, memory loss, hair loss, and depression. There are a variety of causes of hypothyroidism, and treatment depends on the cause.
propofolPropofol is an intravenous anesthetic drug used for general anesthesia and sedation during surgical procedures. Common side effects of propofol include injection site burning, stinging or pain; low blood pressure (hypotension), reduced cardiac output, elevated blood pressure (hypertension), pause in breathing (apnea), lung impairment (respiratory acidosis), impaired movement, high level of emulsified fats in the blood (hyperlipidemia), and high triglyceride level in blood (hypertriglyceridemia). Abuse of propofol can cause death and other injuries.
succinylcholineSuccinylcholine is a skeletal muscle relaxant used for medical procedures done under general anesthesia, including tracheal intubation, mechanical ventilation, and surgeries. Common side effects of succinylcholine include postoperative muscle pain, jaw rigidity, muscle twitch (fasciculation), respiratory depression, cessation of breathing (apnea), low or high blood pressure (hypotension or hypertension), irregular heart rhythms (cardiac arrhythmias), slow or rapid heartbeat (bradycardia or tachycardia), cardiac arrest, increase in intraocular pressure (IOP), high blood potassium levels (hyperkalemia), severe life-threatening drug reaction with excessively high temperature (malignant hyperthermia), salivary gland enlargement, excessive salivation, rash, hypersensitivity reactions, and others.
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