Serife Tuba Liman

Necessity for additional incisions with the cervical Collar incision to remove retrosternal goiters

PurposeRetrosternal goiters (RSGs) can be removed transcervically, but additional incisions are sometimes necessary. We examined the factors determining the need for additional incisions to remove an RSG goiter, based on our experience and on an algorithm.MethodsAmong 499 patients who underwent surgery for a goiter, 52 (10.4%) had an RSG removed via a collar incision. Additional incisions were necessary in 11 patients (21% of those with an RSG and 2.2% overall): a partial sternotomy in 4, total sternotomy in 5, and right thoracotomy in 2.ResultsRecurrent nerve paralysis developed in two patients and one patient had a tracheal laceration. There was no mortality. A diagnosis of adenomatous goiter was confirmed in all patients.ConclusionsAdditional incisions can be made if thyroidectomy cannot be done transcervically and if the goiter extends to the level of the aortic arch. If the thyroid gland extends below the aortic arch and the lateral diameter of the goiter is greater than 10 cm, a partial sternotomy may be required. Total sternotomy is needed when an RSG extends caudally to the azygos vein, if it is located in the retrotracheal or retroesophageal space, or if it is recurrent or ectopic. Coexisting lung disorders and goiters extending to the left atrium also require thoracotomy.

Spontaneous Rupture of a Giant Diaphragmatic Hydatid Cyst into the Intrapleural Space

Objective: We report a case of giant diaphragmatic hydatid cyst which ruptured spontaneously into the intrapleural space in a patient with coexistent giant hepatic hydatid cyst. Clinical Presentation and Intervention: A 62-year-old female was admitted for dyspnea, nausea, vomiting, and right thoracic pain. Clinical findings, laboratory and radiological examinations including multislice computed tomography scan were consistent with the diagnosis of a giant diaphragmatic hydatid cyst which ruptured into the intrapleural space. Surgical intervention was performed through thoracotomy and phrenotomy in a one-stage operation for both cysts. Conclusion: This case shows that hydatid cysts of the diaphragm can rupture into the intrapleural space spontaneously. One-stage operation through thoracotomy may be successful for the surgical intervention for diaphragmatic hydatid cysts with coexistent hepatic cyst.

Characterization of Malignant Thrombus in an Invasive Thymoma with Intravascular Growth

We report an unusual case of an invasive thymoma with a thrombus in the right atrium and describe the radiological findings consistent with the malignant nature of the thrombus. The thrombus showed significant enhancement on computerized tomography images similar to the tumoral mass. On magnetic resonance imaging, both the tumor and the thrombus have heterogeneously high signal intensities on T2-weighted images. On diffusion-weighted images they both exhibit high signal intensity and low apparent diffusion coefficient (ADC) values which support the malignant nature of the thrombus and the mass.

Congenital tracheal diverticulum seen in adult age

Figure 1: 65-year old male patient with right-sided tracheal diverticulum. (a) Diverticulum opening in posterolateral tracheal wall, virtual bronchoscopic view, (b) axial and (c) coronal section of thorax CT. Arrow: the hole in the postero-lateral wall of trachea, *main carina. Figure 2: 51-year old male patient. (a) Axial, (b) coronal section of thorax CT showing air-filled bilobed tracheal diverticulum. (c) Bronchoscopic appearance of the opening of diverticulum, (d) 3D reconstruction of air way demonstrating posteriorly located diverticulum. Arrow: the diverticulum, *main carina.

Unusual Etiologic Factor of Massive Hemoptysis: Unilateral Absence of Pulmonary Artery

he unilateral absence of pulmonary artery (UAPA) is Ta rare malformation. A 19-year-old male patient was admitted to hospital with massive hemoptysis. Chest X-ray showed a smaller right hemithorax, ipsilateral less vascular marking (Fig 1). Computed tomography demonstrated the absence of the right pulmonary artery (Fig 2A; axial section), the absence of pulmonary vascular bundles in the right side (Fig 2B; coronal section), a patent ductus arteriosus between the left main pulmonary artery and aortic arch (white arrow), dilated bronchial arteries (Fig 2C; axial section,), and diffuse ground-glass opacity in the right lower lobe (Fig 2D; axial section). The patient was evaluated with echocar-

A difficult case: ectopic thyroid, bronchial anomalies, and incidentaloma in a patient with lung carcinoma.

CLINICAL SUMMARY Mediastinal enlargement and a solitary pulmonary nodule were detected on a 68-year-old male patient’s chest radiograph during routine annual examination. Computed tomography and magnetic resonance imaging revealed a lobulated, solid, and well-demarcated right paratracheal mass 6 3 4 3 4 cm in dimension (Figure 1). The solitary, heterogeneous parenchymal mass located in the right upper lobe was 4 3 3 3 3 cm in dimension. Results of thyroid function tests were within reference range. Right tracheal bronchus (bronchus suis) was observed on bronchoscopy. Results of bronchoscopy and bronchial lavage cytologic examination were not diagnostic. Positron emission tomography (PET)–computed tomography revealed metabolic activity both in the parenchymal mass (standard uptake values 8.3 early and 9.6 late) and in the nodule of left thyroid lobe (standard uptake values 4.1 early and 5.1 late; Figure 1). There was no metabolic activity in the mediastinal mass or mediastinal lymph node stations. Computed tomographically guided transthoracic fine-needle aspiration of the parenchymal mass revealed non–small cell lung carcinoma. Thyroid ultrasonography and scintigraphy with sodium pertechnetate Tc 99m showed mixed hypoechoic and hypoactive nodules in both thyroid lobes. Because of the suspicion of retrosternal goiter, scintigraphy with iodine 131 was performed, revealing that the mass took up radioiodine. The diagnosis was expected to be thyroid malignancy with lung metastasis. Ultrasonographically guided fine-needle aspiration biopsy of the nodule in left thyroid gland with positive results on positron emission tomography was performed for definitive diagnosis. Pathologic examination

Radio Antenna Aspiration

W e have had much experience with foreign body aspiration, but children still continue to surprise us with strange aspirated materials. A telescopic radio antenna was observed on the chest roentgeno-gram of a 2-year-old girl (Fig 1A and 1B), located just below the vocal cords and extending to the main carina. It was removed without any complications by rigid bronchoscopy (Fig 1C).

Partial Anomalous Venous Return of Left Superior Pulmonary Vein in Adult

Drainage of one or more pulmonary veins into rightsided circulation instead of the left atrium is a rarely seen anomaly in adults [1–4]. In the preoperative evaluation of a female patient with esophageal carcinoma, axial (Fig 1A), coronal section (Fig 1B), and three-dimensional reconstruction (Fig 1C) of thorax computed tomography demonstrated abnormal drainage of the left superior pulmonary vein to the left brachiocephalic vein. Because pulmonaryto-systemic shunt size was not large and the patient was asymptomatic, surgical correction was not performed. She underwent esophageal carcinoma surgery.