RETROSTERNAL ECTOPIC

THYROID
case report
Dr.JAINAM SHAH(R-2 SUC)
Under guidence of Dr.H.S.ANDHARIA SIR
(Professor and head of unit)
S.V.P HOSPITAL,NHL MEDICAL COLLEGE,AHMEDABAD
 ABSTRACT
• “Retrosternal ectopic thyroid”-a case report by Dr.JAINAM SHAH(R2 suc) under
guidence of DR.H.S.ANDHARIA SIR(Professor and head of unit)S.V.P hospital,NHL
medical college,ahmedabad.

• Presenting a rare case of 42 year old female patient With Re-recurrent Thyroid
neoplam and large retrosternal ectopic thyroid neoplasm in relation to right lobe
of thyroid on ct scan.
• per-operatively,after removal of neck thyroid gland along with retrosternal
extension,ectopic retrosternal thyroid Neoplam was also suspected for which
sternotomy was done and ectopic thyroid was removed.
• ECTOPIC thyroid Is defined as any thyroid tissue not located in its usual position.
• PREVALANCE= 1:1,00,000-3,00,000.
• 1 in 4000-8000 patients with thyroid pathology.
• Mediastinal thyroid is seen in less than 1% of all ectopic thyroid cases.
 INTRODUCTION
• Ectopic thyroid refers to the presence of thyroid tissue in locations other than normal
anterior neck region between 2nd-4th tracheal cartilage.
• It is most common thyroid dysgenesis accounting for 48-60% of the cases.
• PREVALANCE= 1:100000-300000 person and occur in 1:4000-8000 patients with thyroid
disease.
• More common in females.
• The lingual thyroid tissue(at the base or below the tongue) accounts for 90% of these.
• The wall of thyroglossal duct cyst is also a common site for ectopic.
• Mediastinal ectopic thyroid tissue Is very rare(<1%).
• Other sites of ectopic thyroid tissue are along oesophagus,trachea.
• Rare sites for ectopic include retroperitoneum,adrenal gland,skull,lung.
• Most common and reasonable hypothesis to explain ectopic thyroid tissue considers some
defect in differentiation,migration or growth of thyroid tissue during embryogenic life.
• Mutation in genes such as NKX-2,PAX-8,FOXE 1,NKX2-5,TSHR were also reported to play a
role in it.
 CASE
• A 42 year old female patient with complaint of painless,midline neck swelling associated with weight
gain,facial puffiness and irregular menstruation for 1 month.

• No complaint of fever/pain at local site/dysphagia/stridor/hoarseness of voice/intolerance to heat or

cold/sleep disturbance/altered bowel habbits/breathing difficulty or any other neck swelling.

• Patient is G4P2A2L2 and has undergone LSCS twice in 2000 and 2004.
• Patient was in euthyroid state in 2006 and was operated for excision of nodule of right lobe of thyroid
in 2006 which was diagnosed as follicular adenoma on histopathological evaluation.
• Patient was started with thyronorm 50 mg od in 2013
• Patient had recurrent swelling on the same side noted in 2015,CT scan neck(2015) was suggestive of
large colloid goiter in right lobe of thyroid with anterior mediastinal retrosternal extension
measuring approx 7.5*7.5*5 cm compressing and displacing trachea and esophagus to left side.
• Patient was operated for subtotal thyroidectomy in 2015.Was advised CT scan neck and thorax
postoperatively,suggestive of large residual retrosternal goiter.
 CASE
• On examination of the thyroid gland in extended position of neck,transverse scar marks
of previous surgeries is present.
• In the lower neck,smooth soft swelling is present in midline of neck which moves with
deglutition,fluctuation and transillumination negative with deviation of trachea to its
left(trail’s sign) and possitive pemberton’s sign.
• Patient was taking thyronorm 50 mg since 2013 and pre operative thyroid profile was
normal.
• All routine investigations normal.
• Ct scan neck of jan,2019 was suggestive of approx 12*7*8 cm sized lobulsted soft tissue
mass in right sided thyroid and extending into anterior mediastinum with retrosternal
extension measuring 9 cm.
• Lesion abuts and displaces trachea and oesophagus on left side,right Subclavian and
common carotid atery,ascending thoracic aorta,right internal jugular vein,medial end of
right clavicle and posterior part of sternum.
• Right and left lobe of thyroid shows multiple nodules with necrotic areas within it with no
cervical or mediastinal lymphadenopathy.
 MANAGEMENT
• Following clinic examination and ct scan,FNAC was done suggestive of colloid goiter with
cystic changes and it was diagnosed as benign follicular nodule.
• IDLE- bilateral vocal cords normal.
• After normal routine work up and pre operative fitness, patient was operated.
• Under due aseptic precautions with patient in supine position and neck slightly
hyperextended,horizontal incision made over the previous scan site.
• Platysma divided in line with skin incision.fascial layers opened up and upper and lower
flaps raised.
• Extensive fibrosis found due to previous surgeries.sternohyoid and sternothyroid muscles
separated in mindline.
• Re-recurrent thyroid neoplasm along with its retrosternal extension freed from adhesions
By finger dissection.
• Both lobe of thyroid along with right retrosternal extension removed from cervical incision
only and sent for HPE.
• Both RLN and parathyroid glands preserved.
 MANAGEMENT
• Comparing the right lobe of thyroid with retrosternal extension,it was suspected that still
thyroid tissue remained in mediastinum,on exploration of retrosternal space by midline
sternotomy,to our surprise a large mediastinal ectopic thyroid neoplasm was found
without any breech with its covering fascia within the basket of vessels of neck and
thorax
• Dissection done between true capsule and fascia.
• Large ectopic thyroid neoplasm removal done by enucleation haemostasis achieved.
• Tissue sent for HPE.
• Right pleura opened up and icd no 32 put in right side of mediastinum.
• Another icd no 32 kept in anterior mediastinum.
• Sternum closed with sternal wires.
• Closure done in layers.
Pemberton’s Sign
Right lobe of thyroid with smooth surface
removed with its retrosternal extension
 POST OP
• Patient vitally stable.
• no sign or symptom of hypocalcemia,hypothyroidism,change in voice or breathing
difficulty.
• Patient was started with thyroxin 100 mg.
• Anterior mediastinal ICD removal on POD-2.
• Right sided ICD removal on POD-3.
• Patient discharged on POD-6.
• Patient came for regular follow up with no complication or complaints.

• HISTOPATHOLOGICAL ANALYSIS
• Microscopically-section reveal nodular architexture with random irregular
scarring.nodules reveal micro and macro colloid filled thyroid follicles lined by cuboidal
to flatted epithelium.hurtle cell changes also seen along with areas of haemorrhage
and hyalinization.
• Diagnosis-multinodular hyperplasia of thyroid.
 DISCUSSION
• Thyroid gland begins to develop during 3rd week of intrauterine life.
• It appears as an epithelial proliferation in the floor of the pharynx between the tubercular
impar and the copula at a point later indicated by the foramen cecum.
• Subsequently thyroid descends in front of the pharyngeal gut as a bilobed diverticulum.
• Aberrant thyroid tissue may be found anywhere along the path of descent of the thyroid
gland,commonly found in the base of tongue,just behind thr foramen cecum.

• Sites of ectopic thyroid

• Lingual
• Wall of thyroglossal duct cyst wall
• Along the oesophagus and trachea
• Anterior mediastinum
• Adjascent to aortic arch
• In the aorto pulmonary window
• Within upper pericardium
• Interventricular septum

• Rarely thyroid in ovaries is known as “STRUMA OVARIES” and considered as thyroid tissue taratoma.
 DISCUSSION
• Clinical features of retrosternal goitre. -
• mostly Asymptomatic
• Pressure symptoms due to size and location
1. Cough
2. Stridor
3. Breathing difficulty
4. Hemoptysis
5. Dysphagia
6. Hoarseness of voice
• Endocrine dysfunction-mostly hypothyroidism related symptoms;rarely hyperthyroidism
• Significant airway obstruction in young patient is an indication for surgery
• Majority of retrosternal thyroids can be removed transcervically

• Indication for open sternotomy in retrosternal thyroid-

1. Ectopic retrosternal thyroid
2. Malignant cases
3. Thyroid extending into mediastinum
4. Diameter if thyroid exceeding that of inlet
5. Fixed and immobile gland
 DISCUSSION
• Complication-
1. Pressure symptoms
2. Endocrine dysregulation
3. Malignancy(rarely)
4. Complications of surgery such as hypothyroidism,hypocalcemia,haemorrhage,injury to
RLN,infection etc.
 CONCLUSION
• Ectopic thyroid tissue is mostly found on the path of normal descent of thyroid
gland.
• Retrosternal ectopic thyroid is very rare.
• For thyroid minimum surgery performed is HEMITHYROIDECTOMY and not
enucleation of nodule.
• In recurrence or disease involving both lobes of thyroid gland,total thyroidectomy
should be preferred over subtotal or near total thyroidectomyt to prevent
recurrunces, as recurrent surgery is at higher risk of RLN injury and hypo-
parathyroidism. Even the risk of post-op hypothyroidism and hyperthyroidism can
not be avoided by doing subtotal thyroidectomies.
• Risk of RLN damage is minimized if they are properly dissected while performing
total thyroidectomy.
• In cases with high index of suspicion of retrosternal ectopic thyroid or retrosternal
extension of thyroid,sternotomy and exploration of retrosternal space should be
done
• Patient is required to follow up regularly and thyoid hormones needs to be given.
 REFERENCES

• SHWARTZ PRINCIPLES OF SURGERY,10TH EDITION

• LANGHMAN MEDICAL EMBRYOLOGY,13TH EDITION
• FISCHER’S MASTERY OF SURGERY,7TH EDITION
• SABISTON TEXTBOOK OF SURGERY
• BAILEY AND LOVE SHORT PRACTICE OF SURGERY,26TH EDITION