A 61-year-old woman was referred to our center with a 12-month history of subclinical hyperthyroidism. She had undergone subtotal thyroidectomy for a multinodular goiter seven years previously in another center. Thyroid function tests revealed hyperthyroidism. Computed tomography (CT) showed the retrotracheal cervical thyroid in continuity with the posterior mediastinal mass that extended beyond the aortic arch and the azygos vein (Fig. 1). The goiter was causing left shift of the trachea and the esophagus, terminating at the level of the left atrium, below the carina tracheae. Examination of the larynx excluded recurrent nerve paralysis. Spirometry results showed forced vital capacity (FVC) of 3.62 l (109%) and forced expiratory volume in 1 second (FEV1) of 2.88 l (114%).

Fig. 1.

(a) Preoperative chest X-ray. (b) Axial computed tomography (CT) showing a large intrathoracic goiter (IG) in the mediastinum. (c) Coronal CT showing a heterogeneous posterior thyroid mass. (d) Sagittal CT showing IG behind the trachea and the aortic arch.

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Right hemithyroidectomy was scheduled. In the first stage, a cervical approach was used for resection of the residual right thyroid. Extension of the thyroid tissue behind the trachea toward the left side was observed. The mass crossed the mid-line and extended toward the superior thoracic outlet. All surrounding tissue adhesions were removed from the cervical region and the mediastinal section of the thyroid was partially freed with gentle traction, until the superior thoracic inlet was reached. The cervical incision was then packed with gauze and the patient was turned on her left side and a right upper thoracotomy was performed. Resection of the mediastinal section of the thyroid gland was laborious due to the lack of space between the mass, the superior vena cava, the subclavian vein and the brachiocephalic artery. During surgery, a thyroid ima artery originating in the subclavian artery supplying the thyroid was identified. The mass was fully released with gentle traction via the thoracic incision. The pathology report was compatible with multinodular goiter. Progress after surgery was uneventful and the patient was discharged after one week.

A 64-year-old woman was admitted to our center due to a 6-month history of IG. The IG had been identified during a routine evaluation of atrial fibrillation. Thyroid function tests were normal. CT revealed a lobulated mass in the thyroid gland adjacent to the lower pole of the right thyroid lobe (Fig. 2). The mass was seen to extend in a retrotracheal direction to a distance of 3cm below the carina tracheae. Spirometry results showed an FVC of 2.63 l (60%) and an FEV1 of 1.92 l (62%).

Fig. 2.

(a) Axial computed tomography (CT) showing a heterogeneous intrathoracic mass. (b) Preoperative sagittal CT showing a large posterior mediastinal goiter. (c) Coronal CT.

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A cervical approach with lateral thoracotomy for right hemithyroidectomy was selected. First, a cervical Kocher incision was made. The thyroid mass extended toward the left, crossing the mid-line and descending along the superior thoracic inlet. Careful attention was paid to the right laryngeal nerve and to the inferior mesenteric arterial blood supply during dissection of the mass in the thoracic outlet. All adhesions in the right thyroid lobe were removed from the cervical region and dissection continued to above the trachea. The Kocher incision was sutured, and the patient was turned on her left side. The procedure continued with a right lateral thoracotomy. The mediastinal section of the right thyroid gland terminated 3cm below the carina tracheae. The mediastinal pleura was opened and the thyroid mass was completely removed. Pathology testing revealed multinodular goiter. Transient dysphonia occurred during the postoperative period. The patient was discharged after one week.