Surgical treatment of substernal goiter: An analysis of 59 patients

Purpose. Substernal goiter is defined as a thyroid mass of which more than 50% is located below the thoracic inlet. In this article we report the diagnosis, symptoms, thyroid function, treatment, and postoperative complications of 59 patients with substernal goiter. Methods. Between 1992 and 2005, 59 patients underwent surgery for substernal goiter at our institution. The indications for surgery were multinodular goiter in 46 cases, follicular adenoma in two cases, and Hashimoto's thyroiditis in one case. Ten patients were operated on for recurrent thyroid disease. Results. The leading preoperative symptoms were dyspnea (49.2%), dysphagia (13.6%), hyperhidrosis (10.2%), and cardiac dysfunction (6.8%). All but two thyroid glands could be removed through a Kocher transverse collar incision. The most common postoperative complications were persistent (5.1%) or temporary (3.4%) paresis of the recurrent laryngeal nerve, transient hypocalcemia (3.4%), and hematoma (3.4%). A tracheotomy was required in one patient with bilateral vocal cord paresis (1.7%). Conclusions. (1) We conclude that a subtotal thyroidectomy is also the treatment of choice for asymptomatic benign substernal goiter. (2) Transverse collar incision should be the standard approach for most patients. (3) The visual identification of at least two parathyroid glands is essential to prevent permanent postoperative hypoparathyroidism.