Substernal (Retrosternal) Goiter Thyroidectomy

Read the CT yourself - Not the report. Scroll the axial cuts for the level of the narrowest tracheal segment, how narrow it is, and whether that point sits above or below where a tube tip would sit. Compression distal to the tube is not relieved by intubating.

Positional symptoms - The mass shifts with gravity, so ask about breathlessness, hoarseness, or lightheadedness lying flat and whether the patient sleeps propped up. A yes means it obstructs supine: induce in the position they tolerate and be ready to sit them up or roll them lateral.

Loss of tone - A compressed airway can stay patent on the patient's own negative-pressure breathing and collapse once tone and spontaneous effort are removed, so keeping them breathing is the conservative choice whenever you doubt the airway can be secured past the narrowing.

Technique selection - Awake fiberoptic intubation, an inhalational induction preserving spontaneous ventilation, and a standard IV induction all have a place, scaled to how tight and how distal the narrowing is and how symptomatic the patient is.

Rescue plan in the room - If the airway collapses distal to the tube, more laryngoscopy does not help and a rigid instrument past the obstruction does. Have the surgeon gowned and present before induction, a rigid bronchoscope open, and an exchange catheter and smaller tubes to hand.

Great-vessel compression - With superior vena cava or innominate compression on the CT, or facial swelling and distended neck veins, drugs and volume given in the upper body may not reach the heart. Put at least one large-bore IV in a lower extremity.

Sternotomy and bypass backup - Some retrosternal glands cannot be delivered through the inlet. Sternotomy, and at worst the availability of bypass or extracorporeal support, is settled with the surgical and perfusion teams before induction, not after the chest is open.

Nerve monitoring tube - The surface electrodes must sit right at the cords, so place the tube with video laryngoscopy, mark the depth, and confirm it again after the neck is extended and draped, because it migrates with positioning and with traction on the gland.

Relaxant plan with the surgeon - Nerve monitoring only works with twitch present, so agree the plan before induction: a short-acting nondepolarizing agent for intubation or none at all, and no redosing without asking.

Arterial line - Worth placing when the goiter is large, the patient has cardiac disease, or sternotomy is possible, because a chest opening and mediastinal traction on the heart and great vessels need beat-to-beat pressure.

Extubation and tracheomalacia - The rings under a long-standing goiter may be soft and collapse once the tube is out. Extubate awake and sitting up with the surgeon still in the room, confirm air moves around a deflated cuff first, and consider coming out over an exchange catheter.

Neck hematoma - Expanding neck swelling, a voice change, or stridor in the first hours means opening the deep closure at the bedside; venous and lymphatic obstruction swells the larynx faster than the skin bulge suggests. Keep suture scissors with the patient and do not wait for an OR.

Hypocalcemia after thyroidectomy - All four parathyroids are at risk when the whole gland comes out and a substernal dissection displaces them further. Perioral and fingertip tingling starts around 24 to 48 hours and can progress to laryngospasm, so stridor in that window gets an ionized calcium.

Treating the hypocalcemia - symptomatic hypocalcemia gets IV calcium gluconate through a reliable line, with oral calcium and calcitriol as the ward follow-on. Say the plan at handover so it is in place before the tingling starts.

A substernal goiter is a thyroid gland that has grown down through the thoracic inlet into the mediastinum, usually a long-standing multinodular gland in an older patient. The inlet is a fixed bony ring, so the gland has nowhere to expand except against what sits beside it: the trachea deviates and narrows, the esophagus is displaced, and the recurrent laryngeal nerves are stretched or encased. In the largest goiters the mass behaves like any anterior mediastinal mass - it can compress the superior vena cava, innominate vein, or great arteries, and it shifts with gravity, so obstruction that is absent when the patient is sitting up can appear once they are flat and anesthetized. Long-standing compression also thins the tracheal cartilage rings, which stays hidden until the gland that was splinting them is removed.

Positioning and incision - Supine with the head elevated and the neck extended over a shoulder roll. A transverse cervical (Kocher) incision at the base of the neck, usually longer than for a routine thyroidectomy so the mediastinal portion can be delivered.

Exposure - The platysma is divided, subplatysmal flaps are raised, the midline raphe is opened, and the strap muscles are separated off the gland. For a bulky goiter the straps are sometimes divided outright to widen the working space.

Cervical mobilization - The middle thyroid vein is ligated and the superior pole vessels are taken close to the capsule to spare the external branch of the superior laryngeal nerve. The parathyroids and the recurrent laryngeal nerve (RLN) are identified and traced, commonly with intraoperative nerve monitoring.

Delivery of the mediastinal component - The surgeon works a finger around the retrosternal portion and delivers it up through the inlet with blunt dissection and traction. This is the step where the trachea gets manipulated the most and where bleeding from vessels below the inlet is hardest to reach.

Sternotomy when delivery fails - A minority of cases need a partial (manubrial) or full sternotomy: goiters that are truly ectopic or posterior mediastinal, recurrent goiters in a scarred field, invasive malignancy, or a gland whose blood supply arises from mediastinal vessels rather than the neck.

Resection - Total thyroidectomy or lobectomy with isthmusectomy depending on the pathology and how much normal gland remains on the opposite side.

Hemostasis and closure - Hemostasis is tested with a Valsalva maneuver, the strap muscles and platysma are reapproximated, and the skin is closed. Drain use varies by surgeon and does not prevent a hematoma.

Confirm the patient is clinically euthyroid before an elective case. Most substernal goiters are nontoxic multinodular glands, but a toxic one that has not been controlled brings the tachycardia, atrial fibrillation, and thyroid storm risk described in the routine thyroidectomy entry; the substernal anatomy does not change that management.

A superficial cervical plexus block covers the incision well and reduces opioid need, which is worth something in a patient whose airway you want awake and self-supporting at the end. Weigh it against a neck you may need to reassess quickly, and place it on the side the surgeon agrees to.

Give PONV prophylaxis seriously. Retching against a fresh thyroid bed drives venous pressure and is a real contributor to hematoma, so this is a case where the antiemetic plan is airway protection, not comfort.