SURGICAL-MANAGEMENT OF SUBSTERNAL GOITER - ANALYSIS OF 237 PATIENTS

Between 1968 and 1991, 237 patients underwent thyroidectomy for subste rnal goiter. Sixteen of them presented malignancies (6.8%). Mean age o f the 159 women and 78 men was 57.7 years. Twenty-five patients had un dergone previous thyroid surgery. The initial symptoms were cervical m ass (72%), compression (16.2%), hyperthyroidism (13.1%), hypothyroidis m (1.3%), and 5.5 per cent were asymptomatic. Most patients had long-s tanding goiter (mean duration: 12.9 yrs.). All but eight operations we re performed through a cervical incision. There were two postoperative deaths (0.8%), both in patients with advanced neoplasms. Early postop erative complications were hemorrhage (0.8%), dysphonia (4.6%), and tr ansient hypocalcemia (2.9%). Five patients (2.1%) required tracheotomy . Complications were more frequent after total thyroidectomy than part ial resection (P < 0.05), after surgery for malignancy than for benign disease (P < 0.05), and in complex than in simple forms (P < 0.05). O ne hundred ninety-four patients were followed after surgery; dyspnea w as found in two patients (1.0%), dysphonia in seven (3.6%), and hypopa rathyroidism in one. Analysis of our data indicates that I) substernal goiter arose in elderly patients more than a decade later than cervic al goiter; 2) goiters with a ''complex'' endothoracic development had an increased rate of short and long term complications; 3) cancer occu rred in a significant number of patients, without any specific symptom s of malignancy; 4) the group of patients with hyperthyroidism was cha racterized by a significantly longer clinical history than euthyroid p atients; 5) nearly all substernal goiters could be approached through a cervical collar incision; 6) the morbidity and mortality were Tow al so after sternotomy. The absence of alternative treatment, the relativ ely high incidence of malignancy, and the threat of acute airway obstr uction should induce the early removal of all substernal goiters.