The necessity for a thoracic approach in thyroid surgery

Hypothesis: A thoracic approach is commonly required in certain subsets of patients with a mediastinal thyroid mass. Design: A retrospective review. Setting: A tertiary referral center. Patients: Nine hundred seventy-six consecutive patients who underwent thyroid surgery by a single surgeon from June 1, 1991, to March 30, 1999. Symptoms of airway compression, including respiratory distress, dyspnea, hoarseness, dysphagia, and persistent cough, were the most common presenting symptoms. The patients ranged in age from 27 to 89 years (mean, 63 years). Results: Patients in whom the computed tomographic scan and operative findings revealed that at least 50% of the thyroid mass was below the thoracic inlet were considered to have a mediastinal mass. These strict criteria identified 94 patients with a mediastinal thyroid mass. Twenty-seven (29%) of these patients required a thoracic approach. The thoracic approach consisted of 21 partial sternotomies, 5 full sternotomies, and 1 right posterolateral thoracotomy. Fifteen patients had a malignant neoplasm. Fourteen patients had a papillary; carcinoma, and 3 of these patients had a multifocal microscopic papillary carcinoma within a multinodular colloid goiter. One patient had a follicular carcinoma. Seven patients underwent reoperative surgery, 5 for a malignant tumor and 2 for a benign tumor. Five patients had a posterior tumor, and 2 had an aberrant mediastinal thyroid mass. Twenty-two (81%) of the 27 patients who underwent a thoracic approach fell into one of the following categories: malignant neoplasm, reoperation, or aberrant or posterior mediastinal thyroid mass. Conclusions: Subsets of patients with a mediastinal thyroid mass are at considerably increased risk for requiring a thoracic surgical approach. These subsets include patients with malignant mediastinal tumors, patients undergoing reoperative thyroid surgery, and patients with posterior or aberrant mediastinal thyroid masses. Surgeons should be prepared for the increased likelihood of a thoracic approach in these subsets of patients.