Ann Thorac Surg 2007;84:300
© 2007 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Unusual Manifestation of Riedel’s Thyroiditis
Pyng Lee, MDa,*,
Anton Vonk-Noordegraaf, MD, PhDb,
Marinus A. Paul, MD, PhDc,
Tom G. Sutedja, MD, PhDb
a Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
b Department of Pulmonology, Free University Medical Center, Amsterdam, the Netherlands
c Department of Surgery, Free University Medical Center, Amsterdam, the Netherlands
* Address correspondence to Dr Lee, Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, 169608, Singapore (Email: lee.pyng{at}sgh.com.sg).
A 35-year-old woman presented with stridor. A computed tomographic scan of the thorax revealed a mediastinal mass with tracheal and esophageal compression (Fig 1A) and fibrosis of the thyroid (Fig 1B). Mediastinoscopy performed for tissue biopsy was complicated by massive hemorrhage from a brachiocephalic vein injury that necessitated a sternotomy. Diagnosis of Riedel’s thyroiditis (RT) with fibrosing mediastinitis was made, and prednisolone was instituted. The patient improved, but she had dysphagia develop 16 months later. A repeat computed tomographic scan demonstrated a tracheoesophageal fistula (black arrow), which was confirmed by bronchoscopy to have occurred 3 cm below the vocal cords (Fig 2). She underwent successful repair through a cervical incision in which the esophagus was mobilized to close the defect followed by tracheal transection at the second ring to allow repair from within to the pars membrenacea. A strap muscle flap was then placed between the trachea and esophagus, and healing in the postoperative period was uneventful.
Riedel’s thyroiditis is a rare inflammatory disease in which fibrous tissue replaces the normal thyroid and invades the structures of the neck [1]. Multifocal fibrosclerosis of extracervical sites, such as fibrosing mediastinitis may occur in one third of these patients [2]. As thyroid carcinoma mimics RT, biopsy is usually required [3], and mediastinoscopy has been shown to be useful not only to confirm RT, but also for differentiating benign from malignant causes of fibrosing mediastinitis.
Most patients respond to steroids, but if they relapse, a structural cause should be excluded. Tracheoesophageal fistula has been reported with granulomatous mediastinitis [4], but this is the first associated with RT and fibrosing mediastinitis. Although mediastinoscopy in our patient was complicated, it is unlikely that tracheoesophageal fistula could be consequent to the procedure given its late manifestation and initial improvement with steroids. The fistula was also sited between the posterior wall of the trachea and the esophagus, an area not involved in mediastinoscopy. Thus, tracheoesophageal fistula as a complication has never been reported in large series of mediastinoscopy [5].
Extensive surgery for RT is discouraged as fibrosclerosis distorts anatomy and obliterates surgical planes, and caution should be exercised when invasive procedures are contemplated. However, if thyroid biopsy is required, it can be accomplished safely by removing the isthmus, which will also alleviate underlying tracheal compression.
 |
References
|
|---|
- Riedel BM. Die chronische, zur bildung eisenharter tunoren fuhrende entzundung der schilddruse Verh Dtsch Ges Chir 1896;25:101-105.
- de Lange WE, Freling NJ, Molenaar WM, Doorenbos H. Invasive fibrous thyroiditis (Riedel’s struma): a manifestation of multifocal fibrosclerosis? Q J Med 1989;72:709-717.[Medline]
- Wan SK, Chan JK, Tang SK. Paucicellular variant of anaplastic thyroid carcinomaA mimic of Riedel’s thyroiditis. Am J Clin Pathol 1996;105:388-393.[Medline]
- Schowengerdt CG, Suyemoto R, Main FB. Granulomatous and fibrous mediastinits: a review and analysis of 180 cases J Thorac Cardiovasc Surg 1969;57:365-379.[Medline]
- Hammoud ZT, Anderson RC, Meyers BF, et al. The current role of mediastinoscopy in the evaluation of thoracic disease J Thorac Cardiovasc Surg 1999;118:894-899.[Abstract/Free Full Text]
Top
References
