What is the management approach for a retrosternal thyroid?

Management of Retrosternal Thyroid

Surgical resection is the treatment of choice for retrosternal goiters, with most cases (>90%) successfully managed through a standard cervical approach without requiring sternotomy or thoracotomy. 1, 2

Diagnostic Approach

• CT scan is the gold standard imaging modality for evaluating retrosternal goiters, as it provides critical information about the extent of substernal extension, degree of tracheal compression, and relationship to surrounding mediastinal structures 3, 1
• MRI can be used as an alternative when CT is contraindicated, though CT is preferred due to less respiratory motion artifact 4
• Cross-sectional imaging is essential when a goiter is suspected to extend substernally or when there is concern for invasive thyroid cancer 4

Clinical Presentation

• Most patients with retrosternal goiters are symptomatic at presentation, with the most common complaints being 1, 2:
  • Dyspnea and choking sensation (68.8%)
  • Neck mass (75%)
  • Hoarseness of voice (37.5%)
  • Dysphagia (31.3%)
  • Stridor/wheezing (19%)
  • Superior vena cava obstruction (less common)
  • Obstructive sleep apnea (can be a presenting feature) 3

Surgical Management

Surgical Approach

• Cervical approach is sufficient in approximately 91% of cases 1
• Only 2-9% of patients require an extracervical approach such as sternotomy, manubriotomy, or thoracotomy 1, 2
• Video-assisted thoracoscopic surgery (VATS) can be considered as a minimally invasive alternative to sternotomy in selected cases 5

Preoperative Considerations

• Complete preoperative cross-sectional imaging assessment of the trachea and tumor is essential 4
• An experienced surgical team familiar with the unique challenges of retrosternal goiter resection should perform the procedure 1
• Anesthetic considerations are critical, as airway management can be challenging with potential for difficult intubation (reported in 11% of cases) 3

Extent of Surgery

• Total thyroidectomy is usually the operation of choice for retrosternal goiters 3
• Non-surgical management options such as suppressive therapy with thyroxine or radioiodine therapy are generally ineffective for large goiters 3

Outcomes and Complications

• Mortality rate is low (approximately 1.3%) 1
• Potential complications include:
  • Transient recurrent laryngeal nerve palsy (7%) 1
  • Permanent recurrent laryngeal nerve palsy (4%) 1
  • Transient hypoparathyroidism (10%) 1
  • Permanent hypoparathyroidism (2.6%) 1
  • Tracheomalacia (rare) 2
  • Respiratory failure (rare) 1

Risk of Malignancy

• The incidence of malignancy in retrosternal goiters ranges from 2.5-12% 1, 2
• This risk, though low, supports the recommendation for surgical management rather than observation 2

Special Considerations

• Retrosternal goiters are more common on the left side than the right (ratio 3:2) 2
• Secondary or recurrent retrosternal goiters (after previous partial thyroidectomy) occur in approximately 13% of cases and may present additional surgical challenges 1, 6
• Patients with comorbidities such as obesity, cardiovascular disease, and pulmonary hypertension require careful preoperative assessment and management 6

Conclusion

Surgical management is the definitive treatment for retrosternal goiters, with excellent outcomes and symptomatic improvement in most patients. While most cases can be managed through a standard cervical approach, thorough preoperative imaging and an experienced surgical team are essential to ensure optimal outcomes and minimize complications.