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Extension of thyroid goiters or tumors into the chest is uncommon, seen in well under 5% of patients undergoing thyroidectomy. In this situation, the intrathoracic goiter virtually always represents extension of cervical thyroid tissue into the mediastinum, rather than discontinuous aberrant thyroid tissue. Because the thyroid gland derives its blood supply from neck vessels, resection of the substernal thyroid usually can be accomplished using the standard cervical approach. Through a collar incision, the vascular connections of the thyroid gland can be divided while preserving the integrity of the recurrent laryngeal nerves. Then the substernal portion generally can be bluntly mobilized and extracted from the neck. The chest x-ray and computed tomography (CT) scan of a patient with a substernal thyroid gland amenable to transcervical resection alone are shown in Figure I.
Rarely, substernal extension of a massive thyroid goiter or tumor cannot be safely resected using a neck incision alone. In this situation, a transsternal approach must be used along with a collar incision to safely resect the thyroid gland. This may entail performing either a partial or a complete median sternotomy. Lesions dictating the need for full median sternotomy are shown in II, III. This article depicts and describes the technique of resection of substernal thyroid gland using both the transcervical and the transsternal approaches.
Extubating the patient at the conclusion of the operative procedure is done if possible. Occasionally, after resection of a large substernal thyroid, secondary tracheomalacia can occur, which can lead to respiratory distress postoperatively. In such situations, it is prudent to extubate the patient over a bronchoscope, to assess airway integrity. Similar care is advisable in a patient presenting with features of chronic obstruction of the superior vena cava before resection. Otherwise, the vast majority of patients should tolerate immediate extubation.
If significant airway manipulation has been required to mobilize and resect the substernal thyroid, the resultant edema may lead to more subtle symptoms of airway compromise that can progress after extubation. These usually can be easily managed by upright positioning, early diuresis, and racemic epinephrine. Steroid (dexamethasone) therapy generally is not necessary in this circumstance.
The closed-suction drains and mediastinal drains usually can be removed within 48 hours of surgery. Early resumption of a general diet and ambulation are encouraged.