Retrosternal goitres often appear intimidating on imaging, particularly when they extend deep into the mediastinum and cause significant tracheal compression. However, an important surgical principle remains true: the majority of retrosternal goitres can be safely excised through a cervical approach without the need for sternotomy.
We recently managed a 60-year-old patient with a history of progressively enlarging neck swelling for several years. Evaluation revealed a large retrosternal goitre. Fine needle aspiration cytology suggested a multinodular goitre, but cross-sectional imaging demonstrated a massive lesion measuring approximately 12 × 15 cm, extending behind the sternum down to the level of the carina, with significant compression and deviation of the trachea.
Given the extent of mediastinal extension, a multidisciplinary surgical plan was formulated. The strategy included total thyroidectomy with thoracoscopic (VATS) mobilisation of the retrosternal component, while keeping sternotomy as a standby option should safe cervical delivery prove impossible.
Despite the impressive radiological appearance and deep mediastinal extension, meticulous dissection through a cervical incision allowed complete mobilisation and removal of the entire retrosternal component without the need for thoracic intervention or sternotomy.
Particular attention was paid to preservation of the recurrent laryngeal nerves, and both recurrent laryngeal nerves were successfully preserved. Equally encouraging was the airway outcome. Despite longstanding tracheal compression, the patient was extubated safely on the operating table, with no evidence of postoperative tracheomalacia.
The postoperative recovery was uneventful, and the patient continues to do well.
Key Surgical Message
Large size, significant retrosternal extension, and tracheal compression do not automatically mandate sternotomy. With careful preoperative planning, appropriate surgical expertise, and adherence to anatomical principles, most retrosternal goitres can be safely removed through a cervical approach alone, sparing patients the morbidity associated with thoracic access.
This case highlights the importance of individualized surgical planning and reinforces that even giant retrosternal goitres can often be managed successfully through the neck while maintaining excellent functional outcomes.