Surgery of Cervical and Substernal Goiter

Surgery for thyroid goiter presents a unique set of challenges to the surgeon based on goiter size and extent, associated distortion of complex neck base anatomy, and goiter vascularity. Specific goiter characteristics influence the risk of potential upper airway compromise as well as the intraoperative risk of injury to the parathyroid glands and recurrent laryngeal nerves. In this chapter, cervical and substernal goiter definition and clinical presentation are reviewed in addition to typical goiter workup and management options. Special consideration is given to airway assessment in the goiter patient, including a discussion of the potential for airway compromise and specific intubation concerns. Surgical technique for goiter resection is outlined with particular emphasis on strategies to reduce the risk of injury to important anatomic structures that may be distorted, such as the case of a retrotracheal or posterior mediastinal goiter and the associated ventral recurrent laryngeal nerve. In the special case of substernal goiter, specific circumstances that may necessitate the rare need for sternotomy are outlined. Finally, potential postoperative complications are discussed, including recurrent laryngeal nerve paralysis, hypoparathyroidism, and the more controversial rate of tracheomalacia.