Table of Contents

2017 Month : September Volume : 4 Issue : 78 Page : 4639-4642

RETROSTERNAL GOITRE MASQUERADING AS OBSTRUCTIVE SLEEP APNOEA IN A MIDDLE-AGED FEMALE

Ashwani Kumar Dalal1, Usha Rani Dalal2, Amish J. Wani3, Lokesh Anand4, Ashok Kumar Attri5

1. Professor, Department of General Surgery, Government Medical College and Hospital, Chandigarh.
2. Associate Professor, Department of General Surgery, Government Medical College and Hospital, Chandigarh.
3. Junior Resident, Department of General Surgery, Government Medical College and Hospital, Chandigarh.
4. Professor, Department of Anaesthesia, Government Medical College and Hospital, Chandigarh.
5. Professor, Department of General Surgery, Government Medical College and Hospital, Chandigarh.

Corresponding Author:
Dr. Usha Rani Dalal,
Associate Professor, Department of General Surgery,
Government Medical College and Hospital, Chandigarh.
E-mail: dalalakd@gmail.com
DOI: 10.18410/jebmh/2017/927

PRESENTATION OF CASE
Retrosternal goitre grows in a tight compartment between the sternum anteriorly and vertebra posteriorly and are symptomatic due to compression of airway and great vessels. The presence of RSG is, per se, an indication for surgical management. Surgery can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The challenges encountered by the anaesthetist and the surgeon are- difficulty in intubation/ventilation due to compression of airways, hypervascularity and the proximity of the goitre to great vessels.

How to cite this article

Dalal AK, Dalal UR, Wani AJ, et al. Retrosternal goitre masquerading as obstructive sleep apnoea in a middle-aged female. J. Evid. Based Med. Healthc. 2017; 4(78), 4639-4642. DOI: 10.18410/jebmh/2017/927

PRESENTATION OF CASE

Retrosternal goitre grows in a tight compartment between the sternum anteriorly and vertebra posteriorly and are symptomatic due to compression of airway and great vessels. The presence of RSG is, per se, an indication for surgical management. Surgery can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The challenges encountered by the anaesthetist and the surgeon are- difficulty in intubation/ventilation due to compression of airways, hypervascularity and the proximity of the goitre to great vessels. We report a case of a large RSG in a middle-aged obese female who was on CPAP treatment from a physician for the symptoms of obstructive sleep apnoea for 2 years, but with no relief. There was no visible or palpable neck swelling. CECT neck and chest was done in view of worsening of symptoms, which showed heterogenous enhancing mass in superior mediastinum up to carina likely lymph node mass or exophyti thyroid mass after, which she was referred to Surgery Department. Ultrasound findings also suggested colloid goitre of both the lobes and swelling of isthmus, which was continuous with the retrosternal mass. FNAC proved it to be colloid goitre with cystic degeneration. She was euthyroid as per laboratory parameters. Patient was operated by transcervical approach and near total thyroidectomy was performed. Patient was discharged in satisfactory condition. A high index of suspicion for the presence of retrosternal goitre should always be kept in mind in endemic areas of goitre in patient of obstructive sleep apnoea, which is refractory to medical management.

DIFFERENTIAL DIAGNOSIS

There was difficulty in diagnosis, since the patient had no swelling in the neck and she was being investigated for sleep apnoea because of her obesity.

CLINICAL DIAGNOSIS

Retrosternal goitre was first described by Hallen 1749 and first surgically removed by Klein in 1820.1 No uniform definition of retrosternal goitre is described in the literature.1 However, various criteria have been suggested by different authors, thyroid extending 3 cm below sternal notch, extension below thoracic inlet, goitrous mass 50% or more of which is in anterior mediastinum. Incidence of palpable thyroid nodule in general population ranges from 4-7%.2

Diagnosis of RSG is mostly made in 5th-6th decade of life with female-to-male ratio of 4:1.1,3,4 90% are noted in anterior mediastinum and the remaining having extension into posterior mediastinum.1CT is the most important imaging modality as it helps in the complete assessment with regards to the extent of goitre and compression effects on adjacent anatomical structures.

Figure 1. Preoperative CXR Showing

Mediastinal Widening and

Compressed Trachea Anteroposteriorly

 

There is a good consensus that most RSG should be removed for the possibility of potential airway compromise and association of thyroid malignancy.1,5 In most of the cases, the retrosternal goitre maybe removed successfully by transcervical access, however, a sternotomy or lateral thoracotomy maybe required when there is involvement of posterior mediastinum, extension to aortic arch, recurrent RSG, SVC obstruction, malignancy with local involvement, emergency airway obstruction and excessive traction being required for surgery.6OSA occurs when there are repeated

episodes of partial or complete upper airway obstruction during sleep. Described is a patient who was being managed previously on the line of OSA and subsequently diagnosed with RSG. The patient was operated and the goitre was removed via transcervical approach.

 

PATHOLOGICAL DISCUSSION: Histological examination confirmed colloid adenomatous goitre other space-occupying lesions in the mediastinum, including thymomas, dermoid, cysts, pleuropericardial cysts and neurogenic tumors should be considered in the differential diagnosis

 

DISCUSSION AND MANAGEMENT

A 45-year-old obese female presented with complaints of shortness of breath for 1.5 months with history of loud snoring, daytime sleepiness and abrupt awakening with sore throat for 2 yrs. Patient had episodes of choking during night, difficulty in lying supine and history of falling asleep while watching television with morning headache and shortness of breath. No history of pedal oedema or postural or diurnal variation of shortness of breath. She was a known case of hypertension and on tablet amlodipine 5 mg for 3 yrs. Patient was diagnosed as a case of obstructive sleep apnoea and was receiving CPAP for the same from a private practitioner. ECG and 2D echo done were normal. Due to worsening of symptoms, patient was referred to Department of Pulmonary Medicine, Government Medical College and Hospital, thyroidectomy was performed through transcervical approach (Figure 5).

 

At surgery, the upper right and left horn of both lobes were normal. Isthmus and lower part of both lobes were enlarged and going down into anterior mediastinum compressing trachea (Figure 6) anteroposteriorly (size 9*7*3 cm (Figure 3). During surgery, bilateral recurrent laryngeal nerves were identified and preserved. Postoperatively, after extubation, patient developed transient neurapraxia of right vocal cord, which resolved with prednisolone. Patient was discharged on postoperative day 10 in stable condition. Histological examination confirmed colloid adenomatous goitre. On followup, patient was relieved of the compressive symptoms and now could lie down supine without any difficulty.

Figure 2. Postoperative CXR showing

Relieved Compression of Trachea

Figure 3. Intraoperative Specimen of the Goitre

Figure 4. CT Showing Compressed Trachea

Figure 5. Transcervical Incision