Unmasking an Elusive Cause of Dyspnea Post-Thoracic Surgery
Document Type
Conference Proceeding
Publication Date
5-2025
Publication Title
American Journal of Respiratory and Critical Care Medicine
Abstract
Introduction: Post-thyroidectomy complications typically manifest in the immediate perioperative period, with long-term sequelae primarily relating to endocrine function. Here, we present a case of an atypical temporal pattern of respiratory compromise following partial thyroidectomy. Case Presentation: A 70-year-old woman with a history of ischemic cardiomyopathy, implantable cardiac defibrillator (ICD) placement, chronic obstructive pulmonary disease secondary to tobacco use, and known multinodular goiter presented with dyspnea. Initial imaging revealed a mass arising from the right thyroid lobe (RTL), extending into the anterior mediastinum. The patient underwent robotic-assisted thoracoscopic surgery (RATS) for RTL, isthmus, and mediastinal resection. One year following surgery, the patient reported worsening dyspnea. A comprehensive workup was initiated to investigate common etiologies. Pulmonary function tests (PFTs) and a six-minute walk test were performed to assess respiratory capacity and exercise tolerance, yielding unremarkable results. Transthoracic echocardiography was conducted to evaluate cardiac function, which also proved non-contributory to the patient's symptoms. Given the inconclusive nature of these investigations, a repeat computed tomography (CT) scan was ordered. The imaging study revealed significant enlargement of the left thyroid lobe (LTL), measuring 10.6x6.1x7.6 cm, an increase of approximately 50% from the pre-operative dimensions. The hypertrophied LTL demonstrated extension into the anterior mediastinum with consequent rightward tracheal displacement. Discussion: This case presents several noteworthy aspects that contribute to our understanding of post-thyroidectomy complications and the evaluation of progressive dyspnea. The compensatory enlargement of residual thyroid tissue following partial thyroidectomy, while recognized, rarely achieves clinical significance. The 50% volume increase observed in our patient substantially exceeds the typical range of 17-30% reported in the literature, making this case particularly instructive. Initial investigations appropriately focused on common cardiopulmonary etiologies, given the patient's comorbidities and demographic profile. However, the unremarkable results from these studies necessitated consideration of anatomical causes, ultimately revealing the underlying pathology. Three key factors contributed to the complexity of this case. First, the magnitude of compensatory hyperplasia, suggesting potential variability in individual responses to partial thyroidectomy. Second, the presence of substernal extension created an anatomical predisposition for mediastinal compromise. Third, this case raises important questions about optimal surveillance strategies following partial thyroidectomy in patients with substernal goiter. This case highlights an uncommon yet clinically significant etiology of progressive dyspnea that emerged following partial thyroidectomy. It also stresses the importance of including post-thyroidectomy hyperplasia in the differential diagnosis of dyspnea for patients with a history of partial thyroidectomy, particularly when common etiologies have been ruled out
Volume
211
First Page
A7519
Last Page
A7519
Recommended Citation
Smith Z, Faizee F, Smielewski M, Patel VK. Unmasking an elusive cause of dyspnea of post-thoracic surgery. Am J Respir Crit Care Med. 2025 May;211:A7519. doi:10.1164/ajrccm.2025.211.Abstracts.A7519
DOI
10.1164/ajrccm.2025.211.Abstracts.A7519
Comments
American Thoracic Society (ATS) International Conference, May 16-21, 2025, San Francisco, CA