World Journal of Surgery

, Volume 32, Issue 7, pp 1285–1300 | Cite as

Evidence-Based Surgical Management of Substernal Goiter

  • Matthew L. White
  • Gerard M. Doherty
  • Paul G. GaugerEmail author



A number of reports have been published concerning the surgical treatment of substernal goiters; however, there is yet to be a comprehensive review of this body of literature using evidence-based methodology.


This article is a systematic review of the literature using evidence-based criteria and a review of unpublished data from our institution.


Issue 1. Limited level III/IV data suggest that the incidence of cancer in substernal goiters is not higher than the incidence of cancer in cervical goiters. Risk factors for malignancy in substernal goiters may include a family history of thyroid pathology, a history of cervical radiation therapy, recurrent goiter, and the presence of cervical adenopathy (grade C recommendation). Issue 2. Prospective level V data suggest that, for most patients, expert endocrine surgeons utilize an extracervical approach approximately 2% of the time to remove a substernal goiter safely; a sternotomy or thoracotomy appears more likely in cases of a primary substernal goiter or a mass larger than the thoracic inlet (no recommendation). Issue 3. There may be a higher rate of permanent hypoparathyroidism and unintentional permanent recurrent laryngeal nerve injury when total thyroidectomy is performed for removal of a substernal goiter than for removal of a cervical goiter alone (grade C recommendation). Injury of the external branch of the superior laryngeal nerve was not specifically addressed and is almost certainly underreported. Issue 4. The presence of a substernal goiter, especially being present more than 5 years and causing significant tracheal compression, is likely a risk factor for tracheomalacia and tracheostomy (grade C recommendation). Tracheomalacia with substernal goiter is an infrequent occurrence, and many cases of tracheomalacia can be managed without tracheostomy (no recommendation). Issue 5. Prospective level V data suggest that about 5% to 10% of operations for substernal goiters are performed because of recurrent or persistent disease, although retrospective level V data report an even higher rate, up to 37%. The most common initial operations with recurrence or persistence appear to be subtotal or hemithyroidectomy (no recommendation).


Evidence-based recommendations provide reliable information regarding the pathologic findings and operative management of substernal goiters in expert hands.


Goiter Recurrent Laryngeal Nerve Total Thyroidectomy Subtotal Thyroidectomy Permanent Hypoparathyroidism 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Newman E, Shaha AR (1995) Substernal goiter. J Surg Oncol 60:207–212PubMedCrossRefGoogle Scholar
  2. 2.
    Gaitan E (1990) Goitrogens in food and water. Annu Rev Nutr 10:21–39PubMedCrossRefGoogle Scholar
  3. 3.
    Haller A (1749) Disputationes Anatomica Selectae. Gottingen, Vandenhoeck, p 96Google Scholar
  4. 4.
    Klein F (1820) Veber die Austrotting verschiedener geschwulste, besonders jener der Ohrspercheldruse und der Schiddruse; Aussachalung der Schilddruse. J Chir Augenlleilk 12:106–113Google Scholar
  5. 5.
    Allo MD, Thompson NW (1983) Rationale for the operative management of substernal goiters. Surgery 94:969–977PubMedGoogle Scholar
  6. 6.
    Sitges-Serra A, Sancho JJ (2005) Surgical management of recurrent and intrathoracic goiters. In: Clark OH, Duh Q-Y, Kebebew E, (eds.) Textbook of Endocrine Surgery, 2nd edition. Philadelphia, Elsevier Saunders, pp 304–317Google Scholar
  7. 7.
    Katlic MR, Wang CA, Grillo HC (1985) Substernal goiter. Ann Thorac Surg 39:391–399PubMedCrossRefGoogle Scholar
  8. 8.
    Sanders LE, Rossi RL, Shahian DM et al (1992) Mediastinal goiters: the need for an aggressive approach. Arch Surg 127:609–613PubMedGoogle Scholar
  9. 9.
    Dahan M, Gaillard J, Eschapasse H (1989) Surgical treatment of goiters with intrathoracic development. In: Delarue NC, Eschapasse H, (eds.) International Trends in General Thoracic Surgery. Vol 5. Thoracic Surgery: Frontiers and Uncommon Neoplasms. St. Louis, Mosby, pp 240–246Google Scholar
  10. 10.
    Vadasz P, Kotsis L (1998) Surgical aspects of 175 mediastinal goiters. Eur J Cardiothorac Surg 14:393–397PubMedCrossRefGoogle Scholar
  11. 11.
    Goldenberg IS, Lindskog GE (1957) Differential diagnosis, pathology, and treatment of substernal goiter. JAMA 163:527–529Google Scholar
  12. 12.
    McCort JJ (1949) Intrathoracic goiter: its incidence, symptomatology and roentgen diagnosis. Radiology 53:227–236PubMedGoogle Scholar
  13. 13.
    Shaha AR, Alfonso AE, Jaffe BM (1989) Operative treatment of substernal goiters. Head Neck 11:325–330PubMedCrossRefGoogle Scholar
  14. 14.
    Wax MK, Briant TD (1992) Management of substernal goitre. J Otolaryngol 21:165–170PubMedGoogle Scholar
  15. 15.
    Wakeley CPG, Mulvany JH (1940) Intrathoracic goiter. Surg Gynecol Obstet 70:702–710Google Scholar
  16. 16.
    Cohen JP, Cho HT (1994) Surgery for substernal goiters. Oper Techn Otolaryngol Head Neck Surg 5:118–125CrossRefGoogle Scholar
  17. 17.
    Huins CT, Georgalas C, Mehrzad H et al (2007) A new classification system for retrosternal goitre based on a systematic review of its complications and management. Int J Surg Feb 16 [Epub ahead of print]Google Scholar
  18. 18.
    Hashmi SM, Premachandra DJ, Bennett AM et al (2006) Management of retrosternal goitres: results of early surgical intervention to prevent airway morbidity, and a review of the English literature. J Laryngol Otol 120:644–649PubMedCrossRefGoogle Scholar
  19. 19.
    Mack E (1995) Management of patients with substernal goiters. Surg Clin North Am 75:377–394PubMedGoogle Scholar
  20. 20.
    Buckley JA, Stark P (1999) Intrathoracic mediastinal thyroid goiter: imaging manifestations. AJR Am J Roentgenol 173:471–475PubMedGoogle Scholar
  21. 21.
    Hall TS, Caslowitz P, Popper C et al (1988) Substernal goiter versus intrathoracic aberrant thyroid: a critical difference. Ann Thorac Surg 46:684–685PubMedCrossRefGoogle Scholar
  22. 22.
    Rives JD (1947) Mediastinal aberrant goiter. Ann Surg 126:797–810PubMedCrossRefGoogle Scholar
  23. 23.
    Melliere D, Saada F, Etienne G et al (1988) Goiter with severe respiratory compromise: evaluation and treatment. Surgery 103:367–373PubMedGoogle Scholar
  24. 24.
    Sackett DL (1989) Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 95:2S–4SPubMedCrossRefGoogle Scholar
  25. 25.
    Heinrich S, Schafer M, Rousson V et al (2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243:154–168PubMedCrossRefGoogle Scholar
  26. 26.
    Rios A, Rodriguez JM, Canteras M et al (2004) Risk factors for malignancy in multinodular goitres. Eur J Surg Oncol 30:58–62PubMedCrossRefGoogle Scholar
  27. 27.
    Chauhan A, Serpell JW (2006) Thyroidectomy is safe and effective for retrosternal goitre. ANZ J Surg 76:238–242PubMedCrossRefGoogle Scholar
  28. 28.
    Hedayati N, McHenry CR (2002) The clinical presentation and operative management of nodular and diffuse substernal thyroid disease. Am Surg 68:245–251; discussion 251–252PubMedGoogle Scholar
  29. 29.
    Hsu B, Reeve TS, Guinea AI et al (1996) Recurrent substernal nodular goiter: incidence and management. Surgery 120:1072–1075PubMedCrossRefGoogle Scholar
  30. 30.
    Pieracci FM, Fahey TJ 3rd (2007) Substernal thyroidectomy is associated with increased morbidity and mortality as compared with conventional cervical thyroidectomy. J Am Coll Surg 205:1–7PubMedCrossRefGoogle Scholar
  31. 31.
    de Perrot M, Fadel E, Mercier O et al (2007) Surgical management of mediastinal goiters: when is a sternotomy required? Thorac Cardiovasc Surg 55:39–43PubMedCrossRefGoogle Scholar
  32. 32.
    Shemen L, Ko W (2006) Current technique for resection of mediastinal goiter. Ear Nose Throat J 85:609–611PubMedGoogle Scholar
  33. 33.
    Ben Nun A, Soudack M, Best LA (2006) Retrosternal thyroid goiter: 15 years experience. Isr Med Assoc J 8:106–109PubMedGoogle Scholar
  34. 34.
    Batori M, Chatelou E, Straniero A et al (2005) Substernal goiters. Eur Rev Med Pharmacol Sci 9:355–359PubMedGoogle Scholar
  35. 35.
    Chow TL, Chan TT, Suen DT et al (2005) Surgical management of substernal goitre: local experience. Hong Kong Med J 11:360–365PubMedGoogle Scholar
  36. 36.
    Grainger J, Saravanappa N, D’Souza A et al (2005) The surgical approach to retrosternal goiters: the role of computerized tomography. Otolaryngol Head Neck Surg 132:849–851PubMedCrossRefGoogle Scholar
  37. 37.
    Testini M, Nacchiero M, Miniello S et al (2005) Management of retrosternal goiters: experience of a surgical unit. Int Surg 90:61–65PubMedGoogle Scholar
  38. 38.
    Shen WT, Kebebew E, Duh QY et al (2004) Predictors of airway complications after thyroidectomy for substernal goiter. Arch Surg 139:656–659; discussion 659–660PubMedCrossRefGoogle Scholar
  39. 39.
    Erbil Y, Bozbora A, Barbaros U et al (2004) Surgical management of substernal goiters: clinical experience of 170 cases. Surg Today 34:732–736PubMedCrossRefGoogle Scholar
  40. 40.
    Parra-Membrives P, Sanchez-Blanco JM, Gomez-Rubio D et al (2003) Retrosternal goiters: safety of surgical treatment. Int Surg 88:205–210PubMedGoogle Scholar
  41. 41.
    Adegboye VO, Ogunseinde OA, Obajimi MO et al (2002) Pattern of intrathoracic goiter in Ibadan, Nigeria. Niger Postgrad Med J 9:226–232PubMedGoogle Scholar
  42. 42.
    Cui Y, Zhang Z, Li S et al (2002) Diagnosis and surgical management for retrosternal thyroid mass. Chin Med Sci J 17:173–177PubMedGoogle Scholar
  43. 43.
    Arici C, Dertsiz L, Altunbas H et al (2001) Operative management of substernal goiter: analysis of 52 patients. Int Surg 86:220–224PubMedGoogle Scholar
  44. 44.
    Shai SE, Chen CY, Hsu CP et al (2000) Surgical management of substernal goiter. J Formos Med Assoc 99:827–832PubMedGoogle Scholar
  45. 45.
    Ozdemir A, Hasbahceci M, Hamaloglu E et al (2000) Surgical treatment of substernal goiter. Int Surg 85:194–197PubMedGoogle Scholar
  46. 46.
    Dedivitis RA, Guimaraes AV, Machado PC et al (1999) Surgical treatment of the substernal goitre. Int Surg 84:190–192PubMedGoogle Scholar
  47. 47.
    Netterville JL, Coleman SC, Smith JC et al (1998) Management of substernal goiter. Laryngoscope 108:1611–1617PubMedCrossRefGoogle Scholar
  48. 48.
    Nervi M, Iacconi P, Spinelli C et al (1998) Thyroid carcinoma in intrathoracic goiter. Langenbecks Arch Surg 383:337–339PubMedCrossRefGoogle Scholar
  49. 49.
    Moran JC, Singer JA, Sardi A (1998) Retrosternal goiter: a six-year institutional review. Am Surg 64:889–893Google Scholar
  50. 50.
    Pulli RS, Coniglio JU (1998) Surgical management of the substernal thyroid gland. Laryngoscope 108:358–361PubMedCrossRefGoogle Scholar
  51. 51.
    Saha SP, Rogers AG, Earle GF et al (1997) Surgical management of intrathoracic goiter. J Ky Med Assoc 95:421–423PubMedGoogle Scholar
  52. 52.
    Torre G, Borgonovo G, Amato A et al (1995) Surgical management of substernal goiter: analysis of 237 patients. Am Surg 61:826–831PubMedGoogle Scholar
  53. 53.
    Burns P, Doody J, Timon C (2007) Sternotomy for substernal goitre: an otolaryngologist’s perspective. J Laryngol Otol Jul 11:1–5 [Epub ahead of print]Google Scholar
  54. 54.
    Page C, Strunski V (2007) Cervicothoracic goitre: an anatomical or radiological definition? Report of 223 surgical cases. J Laryngol Otol 121(11):1083–1087PubMedCrossRefGoogle Scholar
  55. 55.
    Ahmed ME, Ahmed EO, Mahadi SI (2006) Retrosternal goiter: the need for median sternotomy. World J Surg 30:1945–1948; discussion 1949PubMedCrossRefGoogle Scholar
  56. 56.
    Sancho JJ, Kraimps JL, Sanchez-Blanco JM et al (2006) Increased mortality and morbidity associated with thyroidectomy for intrathoracic goiters reaching the carina tracheae. Arch Surg 141:82–85PubMedCrossRefGoogle Scholar
  57. 57.
    Rios A, Rodriguez JM, Canteras M et al (2005) Surgical management of multinodular goiter with compression symptoms. Arch Surg 140:49–53PubMedCrossRefGoogle Scholar
  58. 58.
    Flati G, De Giacomo T, Porowska B et al (2005) Surgical management of substernal goiters: when is sternotomy inevitable? Clin Ter 156:191–195PubMedGoogle Scholar
  59. 59.
    Mussi A, Ambrogi MC, Iacconi P et al (2000) Mediastinal goitres: when the transthoracic approach? Acta Chir Belg 100:259–263PubMedGoogle Scholar
  60. 60.
    Monchik JM, Materazzi G (2000) The necessity for a thoracic approach in thyroid surgery. Arch Surg 135:467–471; discussion 471–472PubMedCrossRefGoogle Scholar
  61. 61.
    Dimov R, Mitov F, Manchev I et al (1999) Retrosternal (intrathoracic) goiter: diagnosis and surgical treatment. Folia Med (Plovdiv) 41:52–55Google Scholar
  62. 62.
    Al-Suliman NN, Ryttov NF, Qvist N et al (1997) Experience in a specialist thyroid surgery unit: a demographic study, surgical complications, and outcome. Eur J Surg 163:13–20PubMedGoogle Scholar
  63. 63.
    Madjar S, Weissberg D (1995) Retrosternal goiter. Chest 108:78–82PubMedCrossRefGoogle Scholar
  64. 64.
    Clark OH, Levin K, Zeng QH et al (1988) Thyroid cancer: the case for total thyroidectomy. Eur J Cancer Clin Oncol 24:305–313PubMedCrossRefGoogle Scholar
  65. 65.
    Ley PB, Roberts JW, Symmonds RE Jr et al (1993) Safety and efficacy of total thyroidectomy for differentiated thyroid carcinoma: a 20-year review. Am Surg 59:110–114PubMedGoogle Scholar
  66. 66.
    Rosato L, Avenia N, Bernante P et al (2004) Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg 28:271–276PubMedCrossRefGoogle Scholar
  67. 67.
    White ML, Gauger PG, Doherty GM (2007) Central lymph node dissection in differentiated thyroid cancer. World J Surg 31:895–904PubMedCrossRefGoogle Scholar
  68. 68.
    Rios-Zambudio A, Rodriguez J, Riquelme J et al (2004) Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery. Ann Surg 240:18–25CrossRefGoogle Scholar
  69. 69.
    Wilson RB, Erskine C, Crowe PJ (2000) Hypomagnesemia and hypocalcemia after thyroidectomy: prospective study. World J Surg 24:722–726PubMedCrossRefGoogle Scholar
  70. 70.
    Pisanu A, Montisci A, Cois A et al (2005) Surgical indications for toxic multinodular goitre. Chir Ital 57:597–606PubMedGoogle Scholar
  71. 71.
    Rodriguez JM, Hernandez Q, Pinero A et al (1999) Substernal goiter: clinical experience of 72 cases. Ann Otol Rhinol Laryngol 108:501–504PubMedGoogle Scholar
  72. 72.
    Abdel Rahim AA, Ahmed ME, Hassan MA (1999) Respiratory complications after thyroidectomy and the need for tracheostomy in patients with a large goitre. Br J Surg 86:88–90PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Matthew L. White
    • 1
    • 2
  • Gerard M. Doherty
    • 1
  • Paul G. Gauger
    • 1
    Email author
  1. 1.Division of Endocrine Surgery, Department of SurgeryUniversity of MichiganAnn ArborUSA
  2. 2.Department of SurgerySt. Joseph Mercy HospitalAnn ArborUSA

Personalised recommendations