Retrosternal goitre: indications for surgery and operative planning
THE CONTEXT
A retrosternal goitre usually develops through slow growth of a multinodular thyroid into the mediastinum.
Symptoms and treatment selection
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Enlargement within the thoracic inlet may cause dysphagia, tracheal compression and eventually airway symptoms, although most patients have minimal symptoms.
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Consider surgery for significant airway compression, existing symptoms or young patients likely to develop symptoms.
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For elderly patients with incidentally discovered retrosternal goitres, most surgeons favour observation over prophylactic treatment. Management requires balancing risk and benefit.
Choosing and planning the operative approach
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Assess the extent of disease carefully before surgery. More than 95% of retrosternal goitres can be removed through a transcervical approach.
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Factors increasing the likelihood of conversion to open sternotomy include malignant disease, revision surgery, posterior mediastinal extension and a goitre diameter exceeding that of the thoracic inlet.
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When these factors are present, plan a joint procedure with thoracic surgery.
Cross-sectional imaging
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All patients should undergo cross-sectional imaging, ideally in the surgical position.
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When interpreting chest computed tomography, check arm position. Imaging with the arms raised may show a substantially different thyroid position from that seen with the arms down and neck extended.