Department of Otology and Laryngology and Division of Thyroid and Parathyroid Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.
Laryngoscope. 2011 Jan;121(1):68-76. doi: 10.1002/lary.21091.
OBJECTIVES/HYPOTHESIS: Surgery for goiter embodies a unique challenge. Our objective is to provide a comprehensive analysis of cervical and substernal goiter data in two paired articles. This second article focuses on surgical management. The following null hypotheses regarding goiter excision have been tested: 1) there are no goiter-associated risk factors for difficult intubation; 2) there are no predictive risk factors for recurrent laryngeal nerve injury (RLN) or postoperative hypocalcemia; 3) there is no difference in RLN injury with neural monitoring versus without.
A retrospective review of 200 consecutive thyroidectomies meeting inclusion/exclusion criteria for cervical or substernal goiter.
Temporary RLN paralysis occurred in 1.8% of nerves at risk and was significantly lower with recurrent laryngeal nerve monitoring than without. Permanent hypoparathyroidism occurred in 3% overall. Bilateral cervical goiter emerged as a definitive risk factor for difficult intubation (P = .05, univariate), recurrent laryngeal nerve injury (P = .002), and postoperative hypocalcemia (P = .001). Female patients (P = .04) or patients with positive family history (P = .01) were more likely to need repeat surgery. There were no cases of tracheomalacia, and sternotomy was required in 1%.
In this series of patients with extensive goiter, primary and revision surgery were associated with low rate of complications. Surgical complications were associated with bilateral and large goiters suggesting increased caution in these patients.
目的/假设：甲状腺肿的手术具有独特的挑战性。我们的目标是在两篇配对文章中对颈前和胸骨后甲状腺肿数据进行全面分析。本文重点介绍手术治疗。对甲状腺切除术有以下无效假设：1）无与插管困难相关的甲状腺肿相关危险因素；2）无预测喉返神经损伤（RLN）或术后低钙血症的危险因素；3）神经监测与不监测对 RLN 损伤无差异。
对符合颈前或胸骨后甲状腺肿纳入/排除标准的 200 例连续甲状腺切除术进行回顾性分析。
有风险的神经中暂时性 RLN 麻痹发生率为 1.8%，使用喉返神经监测显著低于不监测。总体永久性甲状旁腺功能减退发生率为 3%。双侧颈前甲状腺肿是插管困难（P =.05，单变量）、喉返神经损伤（P =.002）和术后低钙血症（P =.001）的明确危险因素。女性患者（P =.04）或有阳性家族史的患者（P =.01）更有可能需要再次手术。无气管软化病例，胸骨切开术发生率为 1%。
在本系列广泛甲状腺肿患者中，原发性和复发性手术的并发症发生率较低。手术并发症与双侧大甲状腺肿相关，提示在这些患者中应更加谨慎。
