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PubMed This is a summary of 18 peer-reviewed journal articles Updated
Endocrinology

Navigating Large and Substernal Goiters

At a Glance

A substernal multinodular goiter extends behind the breastbone into the chest. CT imaging maps its relationship to the windpipe, swallowing tube, and major blood vessels, while vocal-cord testing and an experienced surgical team help plan safer removal.

While most multinodular goiters stay in the neck, some grow downward into the chest cavity. These are known as substernal or retrosternal goiters [1]. Because they sit behind the breastbone (sternum) and near the heart’s major blood vessels and the lungs, they require specialized diagnostic steps and surgical planning [2][3].

Advanced Imaging for a Clear Map

A standard neck ultrasound cannot “see” behind your collarbone or breastbone. If your doctor suspects your goiter has moved into your chest, they will usually order a CT scan (or occasionally an MRI) of both your neck and chest [1][4]. This imaging is essential for several reasons:

  • Measuring the Airway: The scan allows doctors to measure your windpipe (trachea). While severe tracheal narrowing can contribute to breathing difficulty, symptoms do not perfectly correlate with a single percentage of compression. Your breathing is also affected by how fast the goiter grew, your body position, and your lung health [5][6].
  • Vessel and Esophagus Check: The imaging shows if the goiter is pressing on the esophagus (affecting swallowing) or major veins like the Superior Vena Cava [3][2].
  • Mapping the Depth: It tells the surgeon exactly how deep the goiter goes into the chest cavity (mediastinum) [7][8].

Important Note: CT scans often use IV contrast, which contains iodine. This iodine can delay your ability to undergo radioactive iodine (RAI) scans or RAI treatment for several weeks or months. Be sure to discuss this timing with your endocrinologist.

The Preoperative “Vocal Check”

Before surgery for a large or substernal goiter, your surgeon may recommend a flexible laryngoscopy. In this quick procedure, a doctor uses a small, flexible camera to look at your vocal cords while you speak [9].

  • Baseline Function: It is vital to know if your vocal cords are moving normally before surgery, especially if you already have a hoarse voice or have had prior neck surgery [10][11].
  • Airway Security: Knowing the condition of your vocal cords helps the anesthesia team plan a safe way to place your breathing tube during surgery [12][13].

Specialized Surgical Considerations

Surgery for a substernal goiter is more complex than a standard thyroidectomy. The vast majority of these goiters can still be removed through a standard single incision in the neck, though success rates vary by the surgeon’s experience and the patient’s specific anatomy [14][1]. However, for very deep goiters, a sternotomy (splitting the breastbone) or a thoracic approach may be needed to safely reach the mass [7][14].

Two unique risks for massive goiters include:

  1. Tracheomalacia: If a massive goiter has pressed against the windpipe for many years, the cartilage rings of the windpipe can become soft or weak [13]. Once the goiter is removed, the airway may be prone to collapsing [15]. While some older or specific patient cohorts report higher rates, tracheomalacia is generally uncommon in modern surgical series. If it occurs, you may need to stay on a ventilator slightly longer after surgery to allow the airway to stabilize [13].
  2. Increased Nerve and Parathyroid Risk: Because a large goiter displaces the normal anatomy, the risk of temporary or permanent injury to the recurrent laryngeal nerve (voice nerve) and the parathyroid glands (calcium control) is higher than in routine thyroid surgery [16][17].

Choosing the Right Surgeon

Because of these complexities, patients with substernal or massive goiters are often referred to high-volume endocrine surgeons or multidisciplinary teams at specialized centers [17][18]. Depending on your CT anatomy and hospital protocol, your surgical team may include a thoracic surgeon to assist if a chest-based approach becomes necessary [8][4]. Research shows that experienced teams who frequently handle these complex cases have better results and lower complication rates [1][17].

Common questions in this guide

What does it mean if my multinodular goiter is substernal?
A substernal, also called retrosternal, goiter is an enlarged thyroid, often with multiple nodules, that grows behind the breastbone into the chest. It may press on the windpipe, swallowing tube, or large veins and can require more detailed planning than a goiter confined to the neck.
Why is a CT scan of the neck and chest needed for a substernal goiter?
Ultrasound cannot reliably show the part of a goiter hidden behind the collarbone or breastbone. CT, and sometimes MRI, shows how far it extends and whether it affects the windpipe, esophagus, or major veins. Iodine-containing CT contrast can delay radioactive iodine scans or treatment, so timing should be discussed with the endocrinologist.
Will a substernal goiter always require a chest incision?
No. Most substernal goiters can be removed through an incision in the neck, but a very deep goiter may require a sternotomy or a chest-based surgical approach. The decision depends on the goiter’s depth and anatomy and the team’s experience.
Why might I need a vocal-cord examination before goiter surgery?
Flexible laryngoscopy checks whether both vocal cords move normally before surgery. The result provides a baseline, can identify an existing weakness, and helps the anesthesia team plan how to secure the airway. It is especially useful when a person is hoarse or has had previous neck surgery.
What are the main risks of surgery for a very large goiter?
A very large or long-standing goiter can make the windpipe soft or weak after years of pressure; this is called tracheomalacia and is uncommon in modern surgical series. It can require a longer period on a ventilator after surgery. Large goiters also raise the risk of injury to the voice nerve and the parathyroid glands, which help control calcium.
How should I choose a surgeon for a goiter that extends into my chest?
A high-volume endocrine surgeon or specialized center may be best equipped for a large substernal goiter. Depending on the scan and hospital plan, a thoracic surgeon may also be involved. Ask how often the surgeon performs operations of similar size and depth and how the team would manage airway problems.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What is the lowest point of my goiter extension on the CT scan: does it reach the aortic arch, the carina, or the posterior mediastinum?
  2. 2.What is my minimum tracheal diameter and percentage of airway narrowing according to the cross-sectional imaging?
  3. 3.Are my vocal cords moving normally, and what happens to our surgical plan if you find a pre-existing weakness during the laryngoscopy?
  4. 4.How many substernal goiters of this size and depth do you personally operate on each year?
  5. 5.What is your plan for managing potential tracheomalacia (airway collapse) after the pressure of the goiter is removed?

Questions For You

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References

References (18)
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    Frontiers in endocrinology 2026; (17()):1739552 doi:10.3389/fendo.2026.1739552.

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    A huge forgotten retrosternal goiter causing a superior vena cava syndrome after 20 years of thyroidectomy: A case report.

    Almawaz MY, Kheirbek A, Al Aeddin N, Obaied Alahmar F

    International journal of surgery case reports 2025; (136()):111953 doi:10.1016/j.ijscr.2025.111953.

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    Huge toxic goiter extending to the posterior mediastinum; Case report with literature review.

    Abdullah AS, Bahjat AS, Mohammed AA

    International journal of surgery case reports 2019; (62()):69-72 doi:10.1016/j.ijscr.2019.08.016.

    PMID: 31454617
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    Management of retrosternal goiter: Retrospective study of 72 patients at two secondary care centers.

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    Airway Management in a Patient with Retrosternal Goiter: A Context-Sensitive Airway Management Strategy.

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    Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India 2022; (74(Suppl 2)):2214-2216 doi:10.1007/s12070-020-02083-6.

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    Awake Fiberoptic Intubation for Severe Tracheal Compression Caused by a Multinodular Goiter: A Case Report.

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    The Value of Preoperative Volumetric Analysis by Computerised Tomography of Retrosternal Goiter to Predict the Need for an Extra-Cervical Approach.

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    Peculiar anatomic variation of recurrent laryngeal nerve and EMG change in a patient with right substernal goiter and pre-operative vocal cord palsy-case report.

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This page is for informational purposes only and does not constitute medical advice. Your endocrinologist and surgical team should interpret your imaging and discuss the safest plan for your specific goiter.

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