Surgical Management of Substernal Goiters

Substernal goiters, defined by thyroid tissue descending beneath the thoracic inlet, present unique surgical challenges owing to their variable mediastinal extension and proximity to vital structures. The bulk and position of the gland may compress the trachea, oesophagus and large vessels, leading to dyspnoea, dysphagia and, rarely, superior vena cava syndrome. Surgical management aims to achieve complete resection while minimising morbidity. In the majority of cases, a transcervical route suffices, with meticulous intraoperative dissection and preservation of the recurrent laryngeal nerves and parathyroid glands. Preoperative imaging, particularly computed tomography volumetry, guides the surgical plan by predicting the need for supplementary access. In a subset of patients with deep or posterior mediastinal extension, a combined cervicosternotomy or partial sternotomy may be indicated to ensure safe mobilisation. Advances in intraoperative neural monitoring, energy-based vessel sealing devices and sutureless techniques have contributed to reduced operative times and lowered rates of temporary nerve palsy and hypocalcaemia. A global shift towards standardised definitions and consensus-driven protocols has facilitated the accumulation of outcome data, underscoring the importance of centre experience in achieving low complication rates and avoiding unnecessary extracervical approaches.

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Surgical Management of Substernal Goiters publication trend

The graph below shows the total number of articles in surgical management of substernal goiters across all publications each year (not limited to Nature Index journals).

Technical terms

Substernal goiter: Enlargement of the thyroid gland with more than 50 per cent of its mass extending below the thoracic inlet into the mediastinum.

Cervicotomy: Surgical removal of the thyroid conducted exclusively through an incision in the neck, without opening the chest.

Cervicosternotomy: Combined approach involving both a cervical incision and partial splitting of the sternum to access deep mediastinal thyroid tissue.

Extracervical approach: Any surgical access that extends beyond the neck incision, typically including sternotomy or thoracotomy to reach intrathoracic extensions.

Computed tomography volumetry: Imaging technique that quantifies the three-dimensional size of the mediastinal thyroid component to aid surgical planning.

References

1. The Value of Preoperative Volumetric Analysis by Computerized Tomography of Retrosternal Goiter to Predict the Need for an Extracervical Approach. Balkan Medical Journal (2018).
2. Combined cervicosternotomy and cervicotomy for true retrosternal goiters: a surgical cohort study. Updates in Surgery (2021).
3. Sutureless Thyroidectomy With Intraoperative Neuromonitoring and Energy-Based Device Without Sternotomy for Symptomatic Substernal Goiter Harboring Thyroiditis of Gland Parenchyma. Cureus (2021).
4. Cervical approach to cervico-mediastinal goiters: Experience of a Moroccan ENT tertiary center - Case series. Annals of Medicine and Surgery (2021).