7%) a parathyroid gland transplantation [18] and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and in 4 pleural effusions, treated by medical therapy in 3 cases and by drains in

one. There was no mortality. Discussion In spite of Hedenus reporting successful thyroidectomies in six patients for goiters, which he described as “”suffocating”" [20] in 1821, nowadays airway obstruction due to goiter check details is exceptionally reported in literature [2–5, 7, 9, 14] due to improved diagnostic methods and earlier treatment. Although this dramatic occurrence seems to be more frequent in developing countries due to ignorance and lack of ready access to affordable medical services, in western countries the phenomenon of giant goiters is very uncommon though not completely absent [21, 22]. A truly severe life-treating airway obstruction is, therefore, currently

learn more an extremely rare event [2, 21, 23, 24], also because the tracheal lumen may be progressively compressed without causing symptoms up to 75% [2]. The causes of severe respiratory distress related to non traumatic thyroid disease show four different etiopathogeneses: rapidly progressive pressure on the tracheal lumen by spontaneous intrathyroideal hemorrhage, invasion of the tracheal lumen by primitive or secondary tumors, severe compression from benign or malignant masses

and bilateral vocal cords palsy resulting from infiltration of recurrent nerves from thyroid malignancy. Among the causes, spontaneous hemorrhage is often but not always [25] related to benign condition and is paradoxically the most insidious because it suddenly and unexpectedly appears in its mafosfamide full strength, sometimes in patients without previous history of thyroid disease; consequently diagnosis may be delayed. Indeed, literature [26–28] reports mortality related to this event of up to 27.8% [26]. The most likely explanation for hemorrhage in goiters is thought to be venous bleeding [19]. The adenomatous goiters are usually more fragile than normal thyroid because of the increased vascular flow and the lack of a true capsule; these aspects easily explain the great propensity for injury by blunt trauma [29], or iatrogenic bleeding resulting from fine-needle aspiration biopsy [30, 31]. In the spontaneous thyroid hemorrhage, however, the mechanism is unclear. Johnson [32] and Terry [33] proposed that the inciting event for the hemorrhage was increased venous pressure resulting from the Valsalva maneuver. Therefore, most spontaneous cases are found to have an associated external event, such as various forms of light housework, coughing, straining at defecation, crying, which are, however, seemingly insignificant [6].