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Condition Overview
Substernal goiter refers to an enlarged thyroid gland that extends into the chest cavity, beneath the sternum (breastbone). This condition can cause compressive symptoms due to its location and size, potentially affecting the trachea, esophagus, and nearby blood vessels. While goiters are relatively common, substernal goiters are less frequent and often require more complex management.
Substernal goiters may develop slowly over many years and might initially be asymptomatic. As the goiter grows, it can lead to symptoms such as difficulty breathing, especially when lying down, a persistent cough, difficulty swallowing, and a sensation of fullness or pressure in the neck or upper chest. In some cases, substernal goiters can also cause visible swelling at the base of the neck.
Diagnosis typically involves a combination of physical examination, imaging studies such as chest X-rays, CT scans, or MRI, and thyroid function tests. Fine-needle aspiration biopsy may be performed to assess the nature of the thyroid tissue and rule out malignancy. Because these large thyroid glands involve both the chest and the neck, finding a surgeon who is comfortable operating in this region is rare. In some cases, shrinking the thyroid with Thyroid Artery Embolization (TAE) can be a good first step.
Treatment Options
- Thyroid Lobectomy
- Description: This surgical procedure involves the removal of one of the two lobes of the thyroid gland. It may be recommended if the goiter is predominantly confined to one lobe and causing significant symptoms.
- Indications: Single-lobe involvement, symptomatic goiters, suspicion of malignancy.
- Total Thyroidectomy
- Description: Total thyroidectomy involves the complete removal of the thyroid gland. This procedure is typically indicated when the goiter is large, involves both lobes, or there is a suspicion of cancer.
- Indications: Large goiters, bilateral involvement, confirmed or suspected malignancy.
- Thyroid Artery Embolization (TAE)
- Description: TAE is a non-surgical procedure where an interventional radiologist uses a catheter to access the feeding vessels of the goiter. Material is then injected into these vessels which obstructs blood flow, causing the thyroid to shrink overall. This can be a very effective strategy in the short term, but little is known about long term benefits, and it may work best in combination with surgery to remove the risk of future regrowth. Because these vessels are accessed via the carotid artery, there is a risk of stroke.
- Indications: Thyroid goiter that extends into the chest, strong desire to avoid thyroid surgery when other treatments have failed.
- Thyroidectomy with sternotomy (sternal split)
- Description: Occasional, when the thyroid is very large or extends very low into the chest, the top part of the breast bone must be divided. This access is similar to what is required with open heart surgery in the most significant cases, but can sometimes be done via a partial sternotomy. Regardless, recovery is much more involved than with typical thyroid surgery. With an experienced surgeon, it is very rare that a sternotomy would be required to remove a substernal goiter.
- Indications: Substernal malignancy, extremely large substernal goiter
Management of substernal goiter requires careful evaluation and a tailored approach to address both the compressive symptoms and the underlying thyroid pathology. Collaboration between endocrinologists, surgeons, and radiologists is essential to ensure optimal outcomes for patients. Experience can mean the difference between a very invasive surgery with a long recovery and a shorter surgery with a prompt recovery and fewer risks. Having an experienced team such as that at the Russell Center ensures that you will have access to the widest range of options for your substernal goiter.
