Case reportPatient-tailored management of an asymptomatic massive substernal goiter presenting as brachiocephalic vein occlusion. Report of a case and review of sternotomy indications

- Substernal goiter definition is controversial, while they are generally defined as goiters which at least 50% of the thyroid mass extends bellow the thoracic inlet.
- Our patient had a massive substernal multinodular goiter, the left lobe of which caused compression of the braciocephalic vein with symptoms from his left upper extremity.
- The massive size of the gland along with the strict adhesion of the isthmus and left thyroid lobe to the brachiocephalic vein led to the decision of performing a median sternotomy.
- Despite the extensive procedure, patient recovery was uneventful.
- The lack of a uniform definition on substernal goiter and the diversity of thoracotomy indications, lead to a patient-tailored surgical approach. Still the execution of thoracotomy is considered safe in the hands of an experienced surgeon.

IntroductionSubsternal goiters are characterized by the protrusion of at least 50% of the thyroid mass below the level of the thoracic inlet. Still their definition is controversial.Case presentationThe case refers to a 44 year old male who presented to our department due to swelling and a feeling of 'heaviness' of his left upper extremity for the past 6 months. CT scan revealed a massive substernal goiter extending to the great vessels. Intraoperatively, a median sternotomy was performed due to the size of the gland and the close adhesion of the isthmus and lower left thyroid lobe to the brachiocephalic vein. Resection of the gland revealed the vein to have a cord-like shape, leading to reduced venous return and upper extremity symptoms. Recovery was uneventful for the patient who was discharged on the 7th postoperative day.DiscussionWhile most substernal goiters can be surgically managed through a cervical incision, there are cases in which a median sternotomy is indicated. Those cases include excessive gland size, thoracic pain, ectopic thyroid tissue and the extent of the goiter to the aortic arch. Median sternotomy is associated with a number of intra and postoperative complications, although when performed by an experienced surgeon, mortality and morbidity rates along with long-term recovery are not affected.ConclussionThe lack of a uniform definition and variety of indications, lead to a patient-tailored approach regarding the execution of sternotomy during surgical management of massive substernal goiters.