Operative treatment of substernal goiters

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Abstract
This report describes the operative experience in 72 patients with substernal goiters treated over the past 5.5 years. Even though the incidence of multinodular goiter has decreased in the United States due to the routine use of iodized salt, we continue to see a large number of patients with massive goiters, predominantly from Carribean Islands. The diagnosis of substernal goiter was made on clinical examination augmented by such radiologic studies, as chest x-ray, barium esophagograms, airway films, and CT scans. Computed tomographic (CT) scanning was particularly helpful in evaluating the extent of substernal extension. Confirmation of the extent of disease was made at the time of operation. Ninety percent of the patients had tracheal deviation and 85% were symptomatic from airway compression. Esophageal compression was noted in 60% of the patients. All patients had a long history of goiter with recent onset of pressure symptoms. Flow-volume-loop studies were performed in 44% of the patients and were useful in the evaluation of pressure symptoms. However, the decision for operation was made primarily based on clinical evaluation of signs and symptoms. Sixteen patients in this group were admitted with acute airway distress requiring airway intubation or semi-emergency decompression. Only 1 patient required mediastinal splitting, while all others were operated by the cervical approach. The decision as to the extent of thyroidectomy was made at the time of operation. Drains were routinely used because of the large dead space. One patient developed a hematoma in the recovery room and required re-exploration. There were no instances of recurrent laryngeal nerve palsies or of hypoparathyroidism. Two patients required tracheostomy, 1 because of poor pulmonary reserve and the other because of tracheomalacia. Even with considerable tracheal compression, tracheomalacia was noted in only 1 patient. All the patients were treated with thyroxine postoperatively. Sixty patients had benign diagnosis on pathologic examination; 12 had malignancies. Our data suggest that patients with substernal goiters should be treated operatively, especially if there are pressure symptoms or signs of tracheal compression. Using the cervical approach, 98% of the goiters can be removed easily with minimal morbidity.

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