Surgical management of mediastinal goiters: when is a sternotomy required?

Mediastinal goiters are frequently diagnosed, particularly in the elderly population. However, factors associated with an increased risk of median sternotomy have not been analyzed systematically.

Between 1980 and 2004, a total of 185 patients underwent surgery for mediastinal goiters in our institution. There were 126 women and 59 men with a median age of 68 years (range 24 to 94 years). The goiters were left-sided in 77 patients, right-sided in 69 patients, and bilateral in 39 patients.

Clinical presentation was mainly dyspnea (37 %), palpation of a cervical mass (35 %), superior vena cava syndrome (5 %), dysphagia (4 %) and dysphonia (4 %). Goiters measured between 5 and 23 cm (median 10 cm) and were prevascular (38 %), retrovascular and paratracheal (33 %), and retrotracheal (27 %). Aberrant intrathoracic goiters were observed in 4 patients (2 %). The large majority of goiters could be removed transcervically, regardless of the location and extension of the goiters. A sternotomy was required in 13 patients (6 %), mainly because of recurrent goiter ( P = 0.1), ectopic goiter ( P < 0.001), or invasive carcinoma ( P < 0.001). Superior vena cava syndrome, emergent airway compression, dysphagia, retrotracheal goiter, or crossover goiters were not found to be associated with an increased risk of sternotomy. One patient (0.5 %) died postoperatively from massive intraoperative carcinomatous pulmonary emboli. Histology demonstrated a thyroid carcinoma in 18 patients (10 %).

Surgery for mediastinal goiters should always be considered, even in elderly patients because of the high risk of tracheal compression and the low morbidity of the surgery. Most mediastinal goiters are benign and can be removed through a cervical approach. Sternotomy should only be performed in cases of previous cervical thyroidectomy, invasive carcinoma, or ectopic goiter.