A 51-year-old woman presented to the Accident and Emergency Department at Northern and General Hospital with acute shortness of breath and stridor. She had been treated for asthma for 9 years with bronchodilators and steroids. There was no other relevant past history. Examination revealed a 92-kg woman with severe stridor at rest and a large bilateral multinodular goitre with tracheal deviation to the left. She was clinically and biochemically euthyroid. Computed tomography (CT) scan showed a heterogeneous cervical goitre affecting both thyroid lobes with a large retrosternal component extending posteriorly around the trachea and oesophagus to the level of the carina, causing marked narrowing and anterior displacement of the trachea (Fig. 1). Urgent surgical removal of the retrosternal goitre was recommended to the patient. At cervical exploration a large multinodular goitre was found extending retrosternally. The left thyroid lobe was mobilized and resected. Despite division of the superior pole vessels, the right thyroid lobe appeared fixed within the posterior mediastinum. A right posterolateral thoracotomy was performed. The nature of the goitre in the chest was seen to be different to that in the neck; the gland was hard, white and infiltrating the large veins, trachea and oesophagus. Biopsies were taken and the thoracotomy was closed. Postoperatively the patient was transferred to the intensive care unit for ventilation because of her unresolved upper airway obstruction. Bronchoscopic placement of a tracheal stent and tracheostomy were performed to overcome this. Severe bilateral upper limb and facial oedema developed; venography confirmed a stricture between the right internal jugular vein and the brachiocephalic trunk. An intravascular stent was placed with rapid resolution of limb and facial swelling. Seven days postoperatively she was able to breath spontaneously and ventilation was discontinued. Histological examination of biopsy material from the neck revealed areas of multinodular change. Thoracic mass biopsies revealed areas of thyroid parenchyma that blended with sclerotic/hyaline fibrous tissue. Small aggregates of inflammatory cells (T and B lymphocytes, histiocytes, plasma cells, eosinophils) were seen within the fibrous tissue with a mild deposition of haemosiderin and ANZ J. Surg. (2001) 71, 559–560
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