Causes of goiter Iodine deficiency Surgery for thyroid goiter 50% - PowerPoint PPT Presentation

11/7/2014 Causes of goiter • Iodine deficiency Surgery for thyroid goiter – 50% decrease after implementation of universal salts idealization program in mainland China ( Zhao et al. PLOS One. 2014 ) • Genetic predisposition – Autosomal dominant pattern Bhuvanesh Singh, MD, PhD – monozygotic vs. dizygotic twins Attending Surgeon Memorial Sloan-Kettering Cancer Center – Linkage studies – 14q31, Xp22, others • Tobacco use? ( Knudsen , et al. Thyroid 2002 ) Causes of goiter Management of goiter • Non-Surgical • Surgical – Cosmesis – Fear of malignancy • Increased risk for FTC/Anaplastic Ca • Risk <10% – Airway compromise 1

11/7/2014 Airway issues in goiter Airway Compromise in Goiter lessons4medicos.blogspot.com/2009/01/what-is-this-pemberton-sign.html Evaluation-Physical Findings Evaluation Evaluation • Respiratory insufficiency/stridor • Chest x-ray • Laryngoscopy • Pulmonary function tests – flow volume • Thyroid – consistency, texture, loop studies • Computerized tomography/MRI relationship to clavicles • Barium swallow • Lateral neck 2

11/7/2014 Indications for Surgery in Indications for Surgery in Emergency airway management Substernal Goiters Substernal Goiters Compression effects: Up to 22% develop acute airway obstruction requiring emergent intervention Fear of malignancy: Malignancy reported in 5-15% The majority of cases of SSG are Cosmesis: visible in the neck offering obvious cosmetic significance 3

11/7/2014 Surgical technique: Approach Surgical technique: Approach Surgical technique: Setup Surgical technique: Setup • A wide skin excision • Non-traumatic intubation • Transection of sternothyroid - Discuss intubation with anesthesiologist • • Open Joll’s triangle ET tube well below the vocal cords • - tendency for the tube to slide up Work on surface gland • Paralysis during surgery • Ligate feeding vessels • Role of monitoring • Finger dissection Role of finger dissection Surgical technique: key points Surgical technique: key points • Ligate several inferior thyroid veins carefully • Use Bipolar cautery or Ligasure • The RLN best identified after delivering substernal portion of gland • In difficult cases- retrograde technique dissect RLN near the ligament of Berry • Parathyroids 4

11/7/2014 Role sternotomy Management of RLN • Pre-operative consent • Median sternotomy, clam shell thoracotomy, lateral thoracotomy • Indications Recurrent/isolated mediastinal - goiter Superior vena cava syndrome - Thyroid cancer - • direct extension or metastatic disease 5

11/7/2014 Perioperative management Perioperative management • Placement of suction drain recommended • Most of the patients can be extubated in OR • Traceomalacia rarely an issue -If concern- keep intubated for 24 hrs 6