Treatment of obstructive or substernal goiter
- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
Goiter refers to abnormal growth of the thyroid gland. Patients with longstanding goiters (cervical or substernal) may develop symptoms of obstruction due to progressive compression of the trachea or sudden enlargement (usually accompanied by pain) secondary to hemorrhage into a nodule. The most common obstructive symptom is exertional dyspnea, which is present in 30 to 60 percent of cases, and usually occurs when the tracheal diameter is under 8 mm. Substernal goiter may be detected incidentally on chest radiograph or computed tomography (CT) scan or found because of obstructive symptoms such as dyspnea, wheezing, or cough.
The treatment of obstructive and substernal goiters will be reviewed here. The clinical manifestations and evaluation of goiter and the management of benign nonobstructive goiter are reviewed separately.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Katlic MR, Grillo HC, Wang CA. Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital. Am J Surg 1985; 149:283.
- Allo MD, Thompson NW. Rationale for the operative management of substernal goiters. Surgery 1983; 94:969.
- Miller MR, Pincock AC, Oates GD, et al. Upper airway obstruction due to goitre: detection, prevalence and results of surgical management. Q J Med 1990; 74:177.
- Hedayati N, McHenry CR. The clinical presentation and operative management of nodular and diffuse substernal thyroid disease. Am Surg 2002; 68:245.
- Newman E, Shaha AR. Substernal goiter. J Surg Oncol 1995; 60:207.
- Erbil Y, Bozbora A, Barbaros U, et al. Surgical management of substernal goiters: clinical experience of 170 cases. Surg Today 2004; 34:732.
- Gittoes NJ, Miller MR, Daykin J, et al. Upper airways obstruction in 153 consecutive patients presenting with thyroid enlargement. BMJ 1996; 312:484.
- Pieracci FM, Fahey TJ 3rd. Substernal thyroidectomy is associated with increased morbidity and mortality as compared with conventional cervical thyroidectomy. J Am Coll Surg 2007; 205:1.
- White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg 2008; 32:1285.
- Berghout A, Wiersinga WM, Drexhage HA, et al. Comparison of placebo with L-thyroxine alone or with carbimazole for treatment of sporadic non-toxic goitre. Lancet 1990; 336:193.
- Shimaoka K, Sokal JE. Suppressive therapy of nontoxic goiter. Am J Med 1974; 57:576.
- Pieracci FM, Fahey TJ 3rd. Effect of hospital volume of thyroidectomies on outcomes following substernal thyroidectomy. World J Surg 2008; 32:740.
- Ríos A, Rodríguez JM, Canteras M, et al. Surgical management of multinodular goiter with compression symptoms. Arch Surg 2005; 140:49.
- Sancho JJ, Kraimps JL, Sanchez-Blanco JM, et al. Increased mortality and morbidity associated with thyroidectomy for intrathoracic goiters reaching the carina tracheae. Arch Surg 2006; 141:82.
- Chen AY, Bernet VJ, Carty SE, et al. American Thyroid Association statement on optimal surgical management of goiter. Thyroid 2014; 24:181.
- Testini M, Gurrado A, Avenia N, et al. Does mediastinal extension of the goiter increase morbidity of total thyroidectomy? A multicenter study of 19,662 patients. Ann Surg Oncol 2011; 18:2251.
- de Perrot M, Fadel E, Mercier O, et al. Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg 2007; 55:39.
- Zambudio AR, Rodríguez J, Riquelme J, et al. Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery. Ann Surg 2004; 240:18.
- Moten AS, Thibault DP, Willis AW, Willis AI. Demographics, disparities, and outcomes in substernal goiters in the United States. Am J Surg 2016; 211:703.
- Khan MN, Goljo E, Owen R, et al. Retrosternal Goiter: 30-Day Morbidity and Mortality in the Transcervical and Transthoracic Approaches. Otolaryngol Head Neck Surg 2016; 155:568.
- Shen WT, Kebebew E, Duh QY, Clark OH. Predictors of airway complications after thyroidectomy for substernal goiter. Arch Surg 2004; 139:656.
- Anderson PE, Hurley PR, Rosswick P. Conservative treatment and long term prophylactic thyroxine in the prevention of recurrence of multinodular goiter. Surg Gynecol Obstet 1990; 171:309.
- Röjdmark J, Järhult J. High long term recurrence rate after subtotal thyroidectomy for nodular goitre. Eur J Surg 1995; 161:725.
- Kay TW, d'Emden MC, Andrews JT, Martin FI. Treatment of non-toxic multinodular goiter with radioactive iodine. Am J Med 1988; 84:19.
- Huysmans DA, Hermus AR, Corstens FH, et al. Large, compressive goiters treated with radioiodine. Ann Intern Med 1994; 121:757.
- Bonnema SJ, Knudsen DU, Bertelsen H, et al. Does radioiodine therapy have an equal effect on substernal and cervical goiter volumes? Evaluation by magnetic resonance imaging. Thyroid 2002; 12:313.
- ANATOMIC RELATIONSHIPS
- GOALS OF THERAPY
- OUR APPROACH
- Obstructive symptoms
- Asymptomatic substernal goiter
- Preoperative assessment
- Surgical approach
- - Recurrent laryngeal nerve injury
- - Hypocalcemia
- - Tracheomalacia
- Levothyroxine after surgery
- POOR OPERATIVE CANDIDATES
- Radioiodine therapy
- - Recombinant human TSH
- SUMMARY AND RECOMMENDATIONS