MANAGEMENT OF SUBSTERNAL GOITER

Objective: To analyze the presentation, evaluation and treatment of pa tients with large substernal goiters, with emphasis on the radiographi c evaluation and the results of treatment. Study Design: A retrospecti ve chart review of 150 patients undergoing thyroidectomy at the Vander bilt University Department of Otolaryngology-Head and Neck Surgery. Me thods: Charts of patients undergoing thyroidectomy were reviewed. Thos e with substernal goiter, defined as a major portion of the goiter wit hin the mediastinum, were included in the study. When available, the r adiographic studies were reviewed by a staff neuroradiologist. Results : Twenty-three patients (15.3%) presented with substernal extension of the goiter. Characteristics of these patients included mean age of 59 years, 78% female, symptoms of compression such as dyspnea, choking, and dysphagia (65%), hoarseness (43%), and previous thyroid surgery (3 0%). Seventeen percent were asymptomatic. Preoperative radiographs dem onstrated tracheal compression (73%), tracheal deviation (77%), esopha geal compression (27%), and major vessel displacement (50%). Histology revealed multinodular goiter (16/23, 70%). The average size of the re sected specimen in greatest dimension was 8.0 cm (range, 3.0-14.0 cm) and weighed 148 g (range, 39-426 g). All were successfully approached through a transcervical incision without the need for sternotomy, and total thyroidectomy was performed in 83% of the cases. No major compli cations have been documented, and no evidence of tracheomalacia was en countered. Conclusion: Despite the large size of these goiters and the significant involvement of the major mediastinal structures, all were approached through the transcervical incision. Further, despite signi ficant tracheal involvement, there were no cases of tracheomalacia or major complications. For intraoperative planning, the authors advocate the routine use of preoperative computed tomography scanning.