Thyroidectomy for substernal usually includes goiters with minimal extension in the thoracic cavity and those that are present in the mediastinum (the area surrounding the chest cavity). As per the largest study done, the rate of sternotomy is less than 5%, the complication rates are acceptable, and the mortality is less than 1%. Thus, the outcome of substernal goiter surgery is usually good. However, the rate of complications is higher in individuals older than 60 years of age. They have a higher death rate due to postoperative complications.
In the absence of contraindications, substernal goiter should be treated with early surgery rather than having it run the risk of acute airway distress, especially in younger patients.
With careful preoperative testing and thoughtful consideration of the type of anesthesia, including the type of intubation, preparation for surgery can be optimized. In any case, the surgical team must be ready for complications from massive goiter surgery, such as:
- Airway distress
- Recurrent laryngeal nerve injury
- Temporary or sometimes permanent hypoparathyroidism (low blood calcium levels)
- Hoarseness of voice
- Inability to raise the voice
- Incomplete removal of the thyroid and complications in preserving all the critical structures beneath and around the thyroid gland are frequent events among inexperienced and occasional thyroid surgeons.
- Anesthesia-related complications
How is substernal goiter surgery performed?
Substernal goiter can be removed through a relatively straight forward collar incision in the lower neck. Rarely, a surgeon may open the sternum (chest) to remove the goiter. Opening of the chest in the surgical management of substernal goiter is rarely required. During the procedure:
- The patient is usually given general anesthesia to numb the pain and vitals are monitored throughout the procedure.
- The patient may be positioned with special pillows under the neck to tilt the head back.
- The surgeon makes a cut (incision) in the lower part of the neck just above the collar bone to determine if the mass can be removed without opening the chest. Most of the time, the surgery can be done this way. If the mass is deep inside the chest, the surgeon makes an incision along the middle of the chest bone. All goiters are then removed.
- A tube may be left in place to drain fluid and blood. It is usually removed in 1-2 days.
- The incisions are closed with stitches (sutures).
- The operation generally lasts from 2-3 hours. After surgery, the patient will stay in the recovery room for several hours. They will be monitored closely as they need to recover from the anesthesia.
- Most people take at least 15-30 days to recover. The patient may then be placed on thyroid hormone pills.
Should I be worried about the goiter?
Goiters are noncancerous enlargement of the thyroid gland. They are typically not dangerous unless cancer cells develop in the goitrous thyroid enlargement.
Most common goiters include:
- Multinodular goiter or multinodular goiter: These contain multiple nodules (small, rounded lumps or masses).
- Substernal goiter: This is an enlargement of the thyroid gland that extends underneath the breastbone and possibly in between the lungs.
Goiters may be a result of the over or underproduction of the thyroid hormone or the presence of nodules in the thyroid gland. The risk of a substernal goiter is higher in people who:
- Have certain genes or a family member with goiters.
- Have thyroid problems, such as hypothyroidism or hyperthyroidism.
Signs and symptoms:
- Frequent coughing
- Feeling that something is stuck in the throat
- Food getting stuck in the upper esophagus when swallowing (bread and meat most commonly)
- Waking up at night due to breathlessness
- Breathing problems, especially when lying down
- High-pitched sound while breathing
- If goiters are not causing any symptoms, the doctor may recommend close observation to monitor for any changes or growth over time.
- Medication to normalize abnormal thyroid hormone levels may help decrease the size of goiters.
- Surgery is typically recommended for goiters that are causing symptoms.
- A portion of the enlarged thyroid (if possible) or the entire thyroid gland may need to be removed. This surgical procedure is known as a thyroidectomy.
- When the goiter is caused by a noncancerous thyroid nodule or multiple nodules, a new technique called radiofrequency ablation (RFA) may be used. This is used to shrink the goiter and alleviate pressure-related symptoms without the need for surgery.
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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. January 2006;141(1):82-85. https://pubmed.ncbi.nlm.nih.gov/16415416/