title: Management of substernal goiter.
abstract: OBJECTIVE
  To analyze the presentation, evaluation and treatment of patients with large substernal goiters, with emphasis on the radiographic evaluation and the results of treatment.
  
  
  METHODS
  A retrospective chart review of 150 patients undergoing thyroidectomy at the Vanderbilt University Department of Otolaryngology-Head and Neck Surgery.
  
  
  METHODS
  Charts of patients undergoing thyroidectomy were reviewed. Those with substernal goiter, defined as a major portion of the goiter within the mediastinum, were included in the study. When available, the radiographic studies were reviewed by a staff neuroradiologist.
  
  
  RESULTS
  Twenty-three patients (15.3%) presented with substernal extension of the goiter. Characteristics of these patients included mean age of 59 years, 78% female, symptoms of compression such as dyspnea, choking, and dysphagia (65%), hoarseness (43%), and previous thyroid surgery (30%). Seventeen percent were asymptomatic. Preoperative radiographs demonstrated tracheal compression (73%), tracheal deviation (77%), esophageal compression (27%), and major vessel displacement (50%). Histology revealed multinodular goiter (16/23, 70%), thyroiditis (3/23, 13%), and malignancy (4/23, 17%). The average size of the resected specimen in greatest dimension was 8.0 cm (range, 3.0-14.0 cm) and weighed 148 g (range, 39-426 g). All were successfully approached through a transcervical incision without the need for sternotomy, and total thyroidectomy was performed in 83% of the cases. No major complications have been documented, and no evidence of tracheomalacia was encountered.
  
  
  CONCLUSIONS
  Despite the large size of these goiters and the significant involvement of the major mediastinal structures, all were approached through the transcervical incision. Further, despite significant tracheal involvement, there were no cases of tracheomalacia or major complications. For intraoperative planning, the authors advocate the routine use of preoperative computed tomography scanning.
authors.affiliation: Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences, Department of Otolaryngology, Nashville, Tennessee, USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Netterville
authors.forename: S C
authors.initials: SC
authors.lastname: Coleman
authors.forename: J C
authors.initials: JC
authors.lastname: Smith
authors.forename: M M
authors.initials: MM
authors.lastname: Smith
authors.forename: T A
authors.initials: TA
authors.lastname: Day
authors.forename: B B
authors.initials: BB
authors.lastname: Burkey
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000402:Airway Obstruction / Q000209:etiology; D003680:Deglutition Disorders / Q000209:etiology; D004417:Dyspnea / Q000209:etiology; D004940:Esophageal Stenosis / Q000000981:diagnostic imaging / Q000209:etiology; D005260:Female; D006044:Goiter, Nodular / Q000473:pathology; D006045:Goiter, Substernal / Q000150:complications / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006685:Hoarseness / Q000209:etiology; D006801:Humans; D008297:Male; D008482:Mediastinum / Q000098:blood supply; D008875:Middle Aged; D011300:Preoperative Care; D012086:Reoperation; D012189:Retrospective Studies; D012737:Sex Factors; D013964:Thyroid Neoplasms / Q000473:pathology; D013965:Thyroidectomy / Q000379:methods; D013966:Thyroiditis / Q000473:pathology; D014057:Tomography, X-Ray Computed; D014133:Tracheal Diseases / Q000000981:diagnostic imaging / Q000209:etiology; D014135:Tracheal Stenosis / Q000000981:diagnostic imaging / Q000209:etiology; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000000981:diagnostic imaging / Q000209:etiology