经颈部入路联合选择性T形延长颈部切口完整切除隆突水平巨大胸骨后甲状腺肿：两例病例报告及文献复习

文献信息

中文摘要

背景： 巨大胸骨后甲状腺肿可延伸至隆突或以下，同时保持生物学良性。主要手术挑战不仅在于体积，而在于能否在直视控制气道、下血管、喉返神经（RLN）及甲状旁腺血供的条件下安全游离纵隔部分。我们报告两例隆突水平巨大胸骨后甲状腺肿的老年患者，以说明在单纯颈部切口与选择性T形延长颈部切口之间的个体化手术路径选择。
病例介绍： 两名女性，年龄74岁和81岁，于2025年因巨大胸骨后甲状腺肿接受手术。两人均接受颈部和胸部增强CT、甲状腺功能检查、麻醉评估、多学科手术规划（胸外科支持），以及术前血型鉴定和交叉配血，并按机构方案备血。病例1中，甲状腺肿有较大颈部成分并延伸至隆突。通过颈部切口实现完整切除，但在困难的下极/胸廓入口分离过程中发生局灶性RLN切断，并立即行端端吻合修复。病例2中，甲状腺肿大部分位于胸骨后，颈部体积很小，并延伸至隆突下方约1 cm。加用T形延长颈部切口以改善暴露，从而在保留RLN的情况下实现可控的完整切除。两例患者估计失血量均少于150 mL。最终病理证实为结节性甲状腺肿。3个月时，病例1喉镜检查显示右侧声带运动受损，但无明显声音嘶哑、主观发声不满、呛咳或临床误吸。病例2无显著喉镜异常或发声/吞咽主诉。两例患者在短期随访期间均无呼吸窘迫、有临床意义的钙/PTH异常、症状性低钙血症或临床复发。
结论： 这两例说明隆突水平巨大胸骨后甲状腺肿需要个体化手术路径选择。当病变仍与颈部甲状腺连续，且纵隔部分、下血管、RLN和甲状旁腺可在直视下安全控制时，对选定患者采用颈部入路可能是合理的。当颈部暴露不充分时，T形延长颈部切口是有效的辅助手段，尤其适用于纵隔深部成分大且颈部体积小的老年患者。仔细处理喉返神经、保护甲状旁腺血供以及术中愿意个体化调整暴露，对于实现完整切除和低并发症率至关重要。

英文摘要

BACKGROUND: Giant retrosternal goiter may extend to the carina or below while remaining biologically benign. The main operative challenge is not size alone but whether the mediastinal component can be safely mobilized under direct control of the airway, inferior vessels, recurrent laryngeal nerve (RLN), and parathyroid blood supply. We report two elderly patients with carina-level giant retrosternal goiters to illustrate individualized surgical route selection between a cervical incision alone and a cervical incision with selective T-shaped extended.
CASE PRESENTATION: Two women aged 74 and 81 years underwent surgery for giant retrosternal goiter in 2025. Both underwent contrast-enhanced CT of the neck and chest, thyroid function testing, anesthetic assessment, multidisciplinary operative planning with thoracic surgical support, and preoperative blood typing and cross-matching with blood products available according to institutional protocol. In Case 1, the goiter had a substantial cervical component and extended to the carina. Complete resection was achieved through a cervical incision, but focal RLN transection occurred during difficult inferior-pole/thoracic-inlet dissection and was repaired immediately by end-to-end anastomosis. In Case 2, most of the goiter was retrosternal with minimal cervical bulk and extended approximately 1 cm below the carina. T-shaped extended cervical incision was added to improve exposure, allowing controlled complete resection with RLN preservation. Estimated blood loss was less than 150 mL in both patients. Final pathology confirmed nodular goiter. At 3 months, Case 1 had impaired right vocal-fold movement on laryngoscopy but no obvious hoarseness, subjective voice dissatisfaction, choking, or clinical aspiration. Case 2 had no significant laryngoscopic abnormality or voice/swallowing complaint. Both patients had no respiratory compromise, clinically significant calcium/PTH abnormality, symptomatic hypocalcemia, or clinical recurrence during short-term follow-up.
CONCLUSIONS: These two cases illustrate the need for individualized surgical route selection in carina-level giant retrosternal goiter. A cervical approach may be reasonable in selected patients when the lesion remains continuous with the cervical thyroid and the mediastinal component, inferior vessels, RLN, and parathyroid glands can be controlled safely under direct visualization. A T-shaped extended cervical incision is an effective adjunct when cervical exposure is inadequate, especially in elderly patients with a deep mediastinal component and minimal cervical bulk. Careful management of the recurrent laryngeal nerve, protection of the parathyroid blood supply, and intraoperative willingness to customize the exposure are essential for achieving complete resection with low morbidity.