Radiologically predicting when a sternotomy may be required in the management of retrosternal goiters

The Use of a Surgical Spoon in the Removal of Substernal Goiter

Goiter with substernal extension is common, with a reported incidence of up to 20% in patients undergoing thyroidectomy. It has been shown that the vast majority of substernal goiters can be removed through a cervical incision. However, if this is not possible, a sternotomy is usually required, which could add significant morbidity to an otherwise routine operation. During substernal mobilization, the surgeon's finger is typically placed under the strap muscles and against the thyroid capsule, hooking around the inferior aspect of the gland to facilitate separation of the gland from its mediastinal attachments. In cases where the length required for successful substernal mobilization is beyond the reach of a surgeon's fingers, the use of an alternative strategy may be required. A surgical spoon is a blunt, curved instrument that can allow safe substernal mobilization while providing the added length needed when digital mobilization is inadequate. Here, we describe the use of a surgical spoon for the safe and successful removal of a goiter with substernal extension unable to be removed with digital manipulation.

Computed Tomography Findings Affecting the Decision of Sternotomy in Substernal Goiter

Objectives

Although thyroidectomy is completed with a cervical incision in most patients with substernal goiter (SG), sternotomies may be required occasionally. The purpose of this study is to examine computed tomography (CT) findings that may predict the need for sternotomy in SG surgery.

Methods

Neck-thoracic CT images of patients who underwent total thyroidectomy with the diagnosis of SG between 2013 and 2022 were retrospectively examined. The patients (n=41) were divided into two groups: sternotomies (n=6) and cervical (n=35). Preoperative pathological data, CT findings, and postoperative complications of the patients were recorded.

Results

The total thyroid volume of the sternotomy group (280.75±127.01 mm3) was significantly greater than that of the cervical group (155.38±74.18 mm3) (p=0.015). The retrosternal thyroid volume (mm3), thyroid craniocaudal, and anterior-posterior dimensions (mm) were significantly greater in the sternotomy group (p=0.001, p<0.001, and p=0.004, respectively). While the majority of mediastinal extension degrees in the cervical group were grade 1 (80%), grade 2 (83%) predominated in the sternotomy group (p=0.001).

Conclusion

The radiological findings of total thyroid volume, retrosternal thyroid tissue volume, retrosternal thyroid length, thyroid anterior-posterior dimension, and mediastinal extension degree on CT are valuable in predicting the decision to perform a sternotomy in SG surgery.

Surgical Management of 48 Patients with Retrosternal Goiter and Tracheal Stenosis: A Retrospective Clinical Study from a Single Surgical Center

Background

Benign retrosternal thyroid goiters can become large enough to compress the trachea and result in tracheomalacia and stenosis. This retrospective study from a single surgical center aimed to study the surgical management of 48 patients with retrosternal goiter and tracheal stenosis diagnosed and treated from January 2017 to December 2021.

Material/Methods

All preoperative contrast-enhanced CT scans showed retrosternal goiter and tracheal stenosis. RG was classified into type I in 28 patients, type II in 12 patients, and type III in 8 patients. TS was classified into grade I in 31 patients, grade II in 11 patients, and grade III in 6 patients. All patients were referred for surgery. Clinicopathologic features and surgical outcomes were recorded.

Results

All operations were successfully performed. There were 41 patients with transcervical incision, 4 with cervical incision+sternotomy, 2 with cervical incision and thoracoscopic surgery, and 1 with cervical incision and surgery via the subxiphoid approach. Two patients presented recurrent laryngeal nerve injury. One patient showed short-term hand and foot numbness. The patients were pathologically diagnosed as simple nodular goiter (n=27), nodular goiter combined with cystic change (n=6), adenomatous nodular goiter (n=10), and thyroid adenoma (n=5). There was no prominent tumor recurrence or gradual TS remission.

Conclusions

This study has highlighted that patients with retrosternal goiter and tracheal stenosis may have comorbidities and require a multidisciplinary approach to management. The choice of anesthesia, surgical approach, and maintenance of the airway during and after surgery should be individualized.

Modified subxiphoid approach for surgical resection of a retrosternal goiter

Backgrounds

Unilateral Video-Assisted Thorascopic Surgery (VATS) is a traditional minimally invasive transthoracic approach for the surgical resection of a subxiphoid goiter. Recently, the subxiphoid approach was recommended for an anterior mediastinal mass. This study aims to investigate the feasibility and efficacy of a modified subxiphoid VATS for the resection of a retrosternal goiter as an alternative transthoracic approach.

Methods

We retrospectively collected all patients who underwent subxiphoid VATS for the resection of a retrosternal goiter from June 2017 to June 2021 in the Zhongshan Hospital or the Zhongshan Hospital Xiamen branch. Ten patients were found. Patient characteristics, perioperative data, and surgical information were collected and further analyzed.

Results

In our study, all 10 patients underwent a thoracoscopic subxiphoid resection of a retrosternal goiter. The mean age was 49.4 years, and all were female. The majority of patients (70%) were asymptomatic. All patients were assessed by CT imaging before surgery. The mean postoperative hospital stay was 4.9 days. The drainage tube was removed 3 days after operation, and the average drainage volume was 73.1 ml. Postoperative pain was mild, with an average pain grade of 2.4 (measured on a scale from 0 to 10, with lower scores indicating less pain). There were no conversions or perioperative complications in these 10 patients.

Conclusions

Most retrosternal goiters can be completely resected through the modified subxiphoid approach after an adequate preoperative evaluation and careful intraoperative management. This thoracoscopic subxiphoid approach is feasible and safe for retrosternal goiter resection.

A large intrathoracic goiter with tracheal stenosis: Complete resection using a robot-assisted thoracoscopic approach

Growing intrathoracic goiters may compress surrounding organs and deteriorate the cardiopulmonary function. Treating such cases requires carefully considering how to maintain oxygenation and resect the tumor with minimal invasiveness without complications. We herein report a surgically resected case of a large intrathoracic goiter‐compressed trachea extending from the right lower pole of the thyroid gland to the carina. We secured the airway by intubation preparing for extracorporeal membrane oxygenation and successfully performed surgical complete resection using a robot‐assisted thoracoscopic and cervical approach. Intrathoracic goiter is a tumor with abundant neovascularity, and the right vagus nerve is displaced in the thoracic cavity, but a robot‐assisted thoracoscopic approach using CO₂ insufflation improved visualization at the narrow apex area of the thoracic cavity. Robot‐assisted thoracoscopic surgery is a useful surgical procedure enabling safe and minimally invasive surgery without recurrent laryngeal nerve palsy or tracheal injury for intrathoracic giant goiters extending into the thoracic cavity.

Surgery for retrosternal goiter: cervical approach

BACKGROUND

Retrosternal goiter refers to when the thyroid gland extends from the neck to the substernal portion, descending below the thoracic inlet into the mediastinum. It is typically accompanied by compressive symptoms, and most patients need to undergo surgery. This retrospective study set out to analyze the surgical approach to retrosternal goiter and to evaluate perioperative complications, with the aim of recommending best surgical technique.

METHODS

We carried out retrospective analysis of 115 patients with retrosternal goiter treated at our center between May 4, 2011 and March 19, 2019. We analyzed patient characteristics, surgical methods, and perioperative complications using SPSS.

RESULTS

Of the 115 patients in our study, 112 underwent thyroidectomy by cervical approach, with only 3 requiring an extracervical approach. The median age of the patients was 52.3 years, and the majority were female (81.74%). Most of the patients (73.91%) experienced no symptoms but were diagnosed with tracheal compression during surgery or preoperative imaging examination. Ninety-eight (85.22%) of our patients underwent preoperative evaluation of their condition by CT imaging. No obvious surgical contraindications were found before thyroid function tests. The mean operation time was 115.11 min, and the average amount of bleeding during surgery was 54.43 mL. The mean postoperative hospital stay was 5.38 days. In 109 cases (94.78%), the goiter was found to be benign, and malignancy was diagnosed in 6 patients (5.22%). Of the 112 patients who were treated with the cervical approach, 7 (6.25%) experienced recurrent laryngeal nerve palsy; 6 of these cases were transitory and 1 was permanent. The number of patients treated by cervical and extracervical approach who experienced transient hypocalcaemia was 23 (20.54%) and 2, respectively. Transient hypoparathyroidism affected 16 patients (14.29%) treated by cervical approach. Two patients had tracheomalacia phenomenon and one patient had pleural effusion after surgery. No cases experienced permanent hypocalcemia, permanent hypoparathyroidism, postoperative hematoma, tracheostomy, or death.

CONCLUSIONS

Retrosternal goiter surgery is challenging for surgeons. The best surgical approach for the patient should be based on CT scan evaluation. In our study, based on preoperative CT imaging and in-operation evaluation, 50% of the tumor volume was located below the thoracic inlet and 50% of the tumor volume was located above the thoracic inlet in almost all of the patients. Both sections could be successfully removed via a cervical incision, and no obvious complications were observed during the perioperative period. With careful planning and execution before surgery and meticulous operation during surgery, most retrosternal goiters can be safely treated by cervical approach.

Thyroiditis process as a predictive factor of sternotomy in the treatment of cervico-mediastinal goiter

Background

About 10% of cervico-mediastinal goiter need to associate cervicotomy with a total or partial sternotomy to allow a safe removal of the goiter.

Aim of this study is to identify preoperative predictors of sternotomy for mediastinal goiter.

Methods

Between January 2008 and December 2015, 586 patients were submitted to total thyroidectomy at Surgical Clinic of Brescia, Italy.

Among these, patients with cervico-mediastinal goiter have been divided in two groups based on the necessity of an associated sternotomy in the operating field: Group 1 (n = 40 patients) did not need sternotomy and Group 2 (n = 4 patients) underwent cervicotomy associated with sternotomy.

Clinical and pathological characteristics of patients were retrospectivelly recorded.

Results

Among study group, 44 patients had cervico-mediastinal goiter. Thoracic CT was performed in all patients: an extension above aortic arch was found in 41 patients (93.18%) while an extention below aortic arch was found in 3 patients (6.82%).

The extension of the goiter below the aortic arch resulted as a predictive value in the choice of surgical treatment (p = 0.0001).

The thyroiditis process was found to be a significant predictive of the extention to a sternotomic approach (p = 0.029).

The years of goiter’s presence were on average 8.40 years in Group 1 and 14.75 years in Group 2.

These parameters proved to be predictive when choosing a cervicotomy with sternotomy.

Conclusions: Our study, despite limitations posed by small sample and its retrospective analisys, highlights the role of goiter’s extention (below the aortic arch), disease length (for more than 14.75 years) and flogistic process (positivity of Tg Ab and anti-TPO-Ab) in the choice of combined (cervicotomic and sternotomic) approach to goiter’s removal.

Surgical management of intrathoracic goitres

BACKGROUND

Intrathoracic goitres (ITG) often present with compressive symptoms and require specialised care by experienced surgical teams. Most ITG can be accessed by a transcervical approach (TCA) and only between 1 and 15% will require an extracervical approach (ECA). Many controversies exist regarding the clinical presentation, evaluation, selection of cases for ECA, surgical technique and outcomes. This paper reviews the recent literature on the management, outcomes and evidence-based treatment strategies of ITG.

METHODS

We conducted a review of the literature on the evaluation, management and outcomes of surgery for ITGs.

RESULTS

The incidence of cancer in the ITGs ranges between 4 and 20%. Multiplanar CT scanning offers the best preoperative evaluation and aids to determine the approach. Most ITG can be accessed by TCA and ECA are only needed in maximum 15% of cases. In experienced hands, the outcome of these surgeries is comparable to thyroid surgery for non-ITG.

CONCLUSIONS

Surgery for ITG is challenging. The experienced surgeon however, with few exceptions can address ITG via TCA, with outcomes comparable to those of uncomplicated thyroid surgery.

Trans-cervical resection of a separate substernal goitre

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A separate substernal goitre is an unusual entity, which may have embryological origin as ectopic thyroid tissue, or residual cervical thyroid tissue following prior thyroid resection.

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Pre-operative imaging via a thyroid nuclear scan and computer tomography (CT) imaging aids in determining its characteristics and for pre-operative planning.

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A trans-cervical resection is preferred due to lower morbidity.

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A trans-cervical resection is achievable when the lesion is accessible and delivered through the thoracic inlet according to CT characteristics.

Introduction

A separate substernal goitre which is not continuous with the main cervical thyroid proves a unique challenge for resection. A trans-cervical approach is preferred but may be hazardous due to the possibility of ectopic thyroid tissue with alternate blood supply.

Presentation of case

A 72 year old female who had a previous left hemithyroidectomy presents with a symptomatic central substernal thyroid mass. Following radiological work-up, the separate goitre was carefully removed via a trans-cervical approach and avoidance of sternotomy. She had a rapid recovery without complication.

Discussion

The anatomy and embryology of substernal masses need to be carefully considered particularly if the mass is ectopic thyroid tissue. Careful pre-operative assessment may determine its nature and anatomical features. Intra-operative dissection requires consideration of blood supply and surrounding structures, but often may be and is best completed via a cervical approach to minimise morbidity. Review of the literature affirms the preference for a trans-cervical approach and offers criteria for successful resection via this method.

Conclusion

Confirming the nature and anatomy of a separate substernal goitre enables successful removal of the mass via a trans-cervical approach with minimal morbidity.

Morbidity of total thyroidectomy for substernal goiter: A series of 70 patients

Total thyroidectomy for substernal goiter occasionally requires a sternotomy associated with a cervical incision. We sought to analyze the postoperative complications of thyroidectomy for substernal goiters in our center and more precisely the complications related to the sternotomy. All patients who underwent total thyroidectomy for substernal goiter in our center between 2007 and 2016 were reviewed retrospectively. Patients with combined cervical incision and sternotomy (ST group, n=16) were compared to those with cervical incision alone (CT group, n=54), with regard to postoperative complications. Risk factors for the occurrence of postoperative complications were investigated in this population. A total of 24 patients (34.2%) had one or more postoperative complications. The incidence of transient hypoparathyroidism and recurrent laryngeal nerve injury were higher in the ST group (P=0.001 and P=0.052, respectively). The median duration of hospitalization was longer in the ST group (P<0.001). Eighteen patients (25.8%) had a malignant tumor on final pathology. In univariate analysis, the following risk factors for transient postoperative hypoparathyroidism were identified: sternotomy, preoperative symptomatic character and thyroid height (P=0.001, P=0.009 and P=0.013, respectively). In multivariable analysis, only sternotomy was an independent risk factor for postoperative transient hypoparathyroidism (OR=4.48 [1.1; 18], P=0.035). Sternotomy is associated with added morbidity that is not negligible. This surgical approach should be reserved for substernal goiters that descend into the posterior mediastinum, below the level of the aortic arch, when there is suspicion of carcinoma with loco-regional invasion, or when the thyroid tissue is located mainly intrathoracically (conical shaped thyroid, asymptomatic goiter, ectopic thyroid).

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

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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.

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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.

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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.

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Despite the extensive procedure, patient recovery was uneventful.

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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.

Introduction

Substernal 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 presentation

The 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.

Discussion

While 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.

Conclussion

The 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.

RETROSTERNAL GOITRES: A PRACTICAL CLASSIFICATION

Background

There is no standard definition for goitres extending below the thoracic inlet and no clear guidelines for pre-operative planning of surgery. The aim of this study is a practical classification of retrosternal goitres (RSG) based on the anatomical , radiological shape and size of the thyroid.

Methods

Retrospective analysis of all thyroidectomies performed in a referral centre between January 2012 and December 2016. Patients with RSGs had a pre-operative CT scan of neck/thorax. Imaging was reviewed to establish features to predict the difficulty of delivering the goitre through the neck incision and to advise the best surgical approach.

Results

847 thyroidectomies were performed with n=98 involving RSGs. TypeA (n=47) are RSG with a shape of a "cone" or pyramid with the apex pointing down. Cervicotomy is the usual approach. TypeB (n=39) are goitres with a shape of a "pyramid' with the apex pointing up, cervicotomy with ± manubriotomy or sternotomy ± thoracotomy maybe required. TypeC (n=6) are thyroid enlargements in the mediastinum connected by a pedicle with the thyroid in the neck. A cervical approach ± manubriotomy or sternotomy ± thoracotomy is needed. TypeD (n=6) are true intrathoracic or "forgotten" goitres. Sternotomy is indicated for thyroids in the anterior mediastinum though a thoracic approach for those located in the posterior mediastinum might be needed.

Conclusion

The shape and size of goitres is important in carefully planning surgery. CT imaging with cross-sectional reconstruction should be analysed before operation. The proposed classification helps treatment planning and allows comparison of outcomes by anatomical complexity.

Diagnostic value of conventional chest radiography in intrathoracic goiters-retrospective analysis of 2570 patients

PURPOSE

Since intrathoracic goiters (IG), either cervico-mediastinal goiters (CMGs) or mediastinal nodules (MNs), can lead to sternotomies and/or evitable reoperations, their detection is mandatory before thyroid surgery. A systematic screening by CT scan or MRI is not conceivable because of their expensiveness. We tested if conventional chest radiography (CCR) could remain a good screening tool for IG before thyroid surgery.

METHODS

In this retrospective study (2554 patients), CCR usefulness was evaluated in relation with patients' complaints, clinical examination, neck US, and anatomical and surgical findings.

RESULTS

CMGs (n = 67) and MNs (n = 42) were symptomatic in 10 and 5 patients, respectively. Clinical examination or neck US suspected their existence in 25 and 13 and 45 and 17 patients, respectively. Among the 50 IG detected by CCR (42 CMGs and 8 MNs), 4 CMGs and 2 MNs were missed by clinical examination or neck US. CCR failed to detect IG in 59 patients (54%): 25 CMGs (37%) and 34 MNs (80%). Twenty-eight IG (9 CMGs and 19 MNs) were discovered during surgery. CCR resulted in false positive in 88 out of 2445 patients (3.5%). CCR potentially avoided reoperation in two patients (a maximum saving of 6160 €, whereas the total cost of CCR was 54,895 €).

CONCLUSIONS

CCR should not be used routinely for the preoperative detection of IG. Surgeons should preferably use clinical examination or neck US and directly perform CT scan when a mediastinal extension is suspected.

Surgical management of substernal goitres at a tertiary referral centre: A retrospective cohort study of 2,104 patients

BACKGROUND

When to use a thoracic approach to treat substernal goitres has often been discussed in the literature. But there are few published reports describing surgical outcomes and associated complications for patients with right-sided vs. left-sided substernal goitres.

OBJECTIVE

This study evaluated the characteristics and clinical outcomes of patients who underwent surgical management of substernal goitres, presenting factors indicating the use of a thoracic approach and differences between right- and left-sided goitre extensions.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral centre.

METHODS

Between January 2007 and December 2012, 2104 patients underwent thyroidectomy at Chang Gung Memorial Hospital and 140 (6.7%) were diagnosed with substernal goitres. Patient medical records were retrospectively reviewed, and data were analysed to assess surgical outcomes.

RESULTS

Seven (5.0%) patients required a thoracic approach for goitre removal. Goitre malignancy was verified in 17 (12.1%) patients. The most common postoperative complication was transient hypoparathyroidism (15.0%). Permanent RLN injury occurred in 4.3% of patients and was significantly more frequent using the thoracic approach. Unilateral extension of a substernal goitre was more common than bilateral extension. Right- and left-sided extensions occurred with equal frequency. The rate of postoperative complications was similar between groups and there were no patient deaths.

CONCLUSION

Chest radiography and thyroid sonography may provide initial radiologic evidence of goitre extension into the superior mediastinum. Computed tomography evaluation of the depth of goitre extension to the tracheal bifurcation was the strongest predictor of the need to use a thoracic approach. There were no significant differences in the clinical features and outcomes of patients with right- and left-sided substernal goitres. The right recurrent laryngeal nerve shows increased susceptibility to damage during thyroid surgery for substernal goitres. The incidence of malignant substernal goitres is similar to that of malignant cervical goitres.

Computed tomography for preoperative evaluation of need for sternotomy in surgery for retrosternal goitre

PURPOSE

The purposes of this study are to evaluate the usefulness of available CT classifications of retrosternal goitre (RSG) to identify patients needing sternotomy and to examine the effect of neck extension on goitre position.

METHODS

From the Scandinavian Quality Register for Thyroid and Parathyroid Surgery, all patients treated for RSG at Sahlgrenska (January 2005 through August 2012) were identified. Medical records and preoperative CT scans were retrospectively reviewed. Paired CT (normal position/neck extension) was done in three patients.

RESULTS

Of 1698 patients undergoing thyroid surgery, 158 (9.3 %) were registered as having RSG, of these 38 were excluded (no preoperative CT n = 27, no RSG at preoperative CT n = 11). Of 120 included patients (71 % females, median age 67 years, rate of malignancy 14 %), 104 were managed with a cervical approach only, 16 (13.3 %) needed sternotomy, of these 13/16 had growth below the aortic arch concavity. Predictors for sternotomy were goitre extension below the aortic arch concavity (positive/negative predictive value (PPV/NPV) 54/97 %, sensitivity/specificity 81/89 %, odds ratio (OR) 36.6, p < 0.001); main mass of RSG to the right of the midline (PPV/NPV 21/95 %, sensitivity/specificity 81/53 %, OR 4.9, p < 0.008); and main mass of RSG retrotracheal (PPV/NPV 31/92 %, sensitivity/specificity 50/83 %, OR 4.8, p < 0.005). The goitre was displaced cranially a mean 11 mm with neck extension, but the relationship to the aortic arch was unchanged.

CONCLUSIONS

RSG extension below the aortic arch concavity was confirmed as a significant risk factor for sternotomy, with a NPV for sternotomy of 97 % for less extensive goitres. CT in neck extension provided no additional clinically relevant information.

Substernal goiter: when is a sternotomy required?

The presence of substernal goiter is, per se, an indication for surgical management. Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The aim of this study was to identify the preoperative predictors of a sternotomy in the management of substernal goiter in order to provide better preoperative planning and patient consent. Between 2005 and 2012, 665 patients were referred to our clinic for thyroidectomy, 42 patients (6.3%) had substernal goiter and were included in this study. All substernal goiters were treated surgically, 38 (90.5%) by a cervical approach and 4 (9.5%) by full median sternotomy. All surgeries were successful, with no major postoperative complications. Minor postoperative complications of transient hypocalcemia and transient paralysis of the recurrent laryngeal nerve occurred in 5 (11.9%) and 2 (4.7%) cases, respectively. Indication of median sternotomy was as follows: extension of goiter below the aortic arch, large thyroid tissue extending towards tracheal bifurcation, and ectopic thyroid tissue in the mediastinum. Substernal goiter can be removed through a cervical incision, but on rare occasions, a median sternotomy may be required.

Is it possible to predict the need for sternotomy in patients undergoing thyroidectomy with retrosternal extension?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'in patients undergoing thyroidectomy for retrosternal goitre, what factors predict sternotomy?' Altogether 165 papers were found as a result of the reported search, of which only 3 prospective studies, 1 review paper and 2 retrospective studies represented the best evidence to answer the clinical question. The authors, journals, date and country of publication, patient group studied, study type, relevant outcomes and results of the papers are tabulated. We conclude that a combination of preoperative clinical and radiological risk factors, alongside informed patient choice can be used to predict the need for sternotomy in thyroidectomy for goitre with retrosternal extension. Clinically, a history of goitre with retrosternal extension beyond 160 months is a risk factor for sternotomy. Thyroid tissue density, posterior mediastinal location and subcarinal extension, as measured using computed tomography (CT) imaging, are independent preoperatively obtained risk factors for sternotomy, which are supported by both prospective and retrospective studies. Thyroid tissue density is the strongest factor and increases the risk of sternotomy 47-fold. Minimal upper sternotomy (sternal-split) can be used instead of median sternotomy where there is evidence of retrosternal extension to the aortic root. CT evidence of an ectopic nodule, a dumbbell-shaped goitre, a conical-shaped goitre constricted by an isthmic thoracic inlet or a thoracic goitre component wider than the thoracic inlet can also predict the need to undergo sternotomy. Finally, informed consent should include a discussion that patients with bilateral multinodular goitre and evidence of intrathoracic extension, who are undergoing total thyroidectomy via cervicotomy, have an independently increased risk of complications, specifically recurrent laryngeal nerve injury. After explanation of these risks, a patient may be unwilling to accept the increased risks of cervicotomy per se versus those of combined cervicotomy and sternotomy.