The Science Journal of the American Association for Respiratory Care

2006 OPEN FORUM Abstracts

SUBSTERNAL GOITER COMPRESSING THE TRACHEA  Gail Bush RRT-NPS, CPFT;

Natalia Mersereau RRT; Mary Zapalo CRT; James Lamberti MD Inova Fairfax Hospital, Falls Church VA.

Introduction:
A goiter is an enlarged thyroid caused by increased thyroid stimulating hormone or iodine deficiency. A substernal goiter extends behind the sternum and into the thoracic cavity. This patient was admitted for a suspected asthma exacerbation. CXR displayed tracheal compression and CT scan revealed the substernal goiter. Substernal goiters should be considered in patients with a history of goiter who present with respiratory distress. Case Report: An 81 year-old female presented with chest pain, shortness of breath and respiratory distress. The evaluating physician initially diagnosed an acute asthma exacerbation. The patient was treated with 125 mg IV methylprednisolone, 1.25mg levalbuterol nebulizer, 2 mg IV morphine sulfate, and 40 mg IV Lasix. The chest x-ray showed a prominent superior mediastinum. CT scan of the chest revealed an enlarged heterogeneous thyroid with a dominant left nodule (approximately 4 x 3.5cm). This goiter compressed the trachea to minimal transverse diameter of 3.7 mm in the upper tracheal region. The patient was admitted to the hospital for stabilization and treatment. Initial pulmonary evaluation described mild respiratory distress with an audible inspiratory stridor heard from across the room. A bedside spirometry was performed with the patient sitting and supine. The study results demonstrated a fixed extrathoracic obstruction superimposed on chronic airflow obstruction. On day 13, a total thyroidectomy was performed. The patient was discharged four days after surgery with no further complications.


Discussion: Substernal goiters often mimic symptoms of other common disorders, such as obstructive airway disorders, thus it is difficult to suspect its presence. Mortality is high if the goiter is undiagnosed. The pathologic process may be overlooked in the early stages when the goiter has only a mild enlargement. This patient had been seen 4 years earlier due to "chest congestion". At that time, it was noted that the patient had right paratracheal enlargement. Nine months prior to this admission, there was an abnormal CXR and the patient was advised to have a CT scan. Had the patient followed the plan of care after the initial CXR, treatment could have been initiated before the size and position of the goiter resulted in respiratory compromise.

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