10.14639/0392-100X-N2746
Objective. Partial or total sternotomy is required for 10% of retrosternal goiter. This study reviewed our experience with an extended cervicotomic approach as an alternative surgical solution for retrosternal goiter.Methods. A retrospective study was performed on patients who underwent partial or total thyroidectomy for retrosternal goiter between 2014 and 2019 at a tertiary medical centre. Data on clinical, radiologic, and pathologic factors were analysed. Peri- and postoperative outcomes were compared between extended and standard cervical approaches to predict the need for an extended cervical approach. Results. The cohort included 265 patients, of whom 245 (92.4%) were treated by standard thyroidectomy. In 17 (6.4%), the standard approach proved insufficient, and the horizontal incision was extended to a T-shape to improve access. The remaining 3 patients required a sternotomy. Use of the extended cervical approach was significantly associated with clinical features such as male gender, diabetes, high body mass index and postoperative hypocalcaemia. Conclusions. The extended cervicotomic approach is an alternative surgical solution for retrosternal goiter, with no increased risk of significant post-operative complications.
text/xml
1827-675X
2746
en
Aviram Mizrachi
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
sternotomy
Extended cervical approach for retrosternal multinodular goiter
Text.Serial.Journal
https://www.actaitalica.it/
44
Thyroid
2024-02-27
2023-09-06
2024-02-28
2024-02-28
21-26
1
Aviram Mizrachi
2024/02/27
10.14639/0392-100X-N2746
21
Department of Otorhinolaryngology – Head & Neck Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
1827-675X
sternotomy
en
26
Extended cervical approach for retrosternal multinodular goiter
https://www.actaitalica.it/article/download/2746/1070
44
ACTA OTORHINOLARYNGOLOGICA ITALICA 2024;44:21-26; doi: 10.14639/0392-100X-N2746




Thyroid


Extended cervical approach for retrosternal
multinodular goiter
Nir Tsur1,2, Lirit Levi1,2, Omry Frig1,2, Noam Koch1, Yossi Eshel1,2, Gideon Bachar1,2, Thomas Shpitzer1,2,
Moshe Yehuda1,2, Yuri Pescovitz2,3, Ory Wiesel2,3, Dean Dudkiewicz1,2, Aviram Mizrachi1,2
1
 Department of Otorhinolaryngology – Head & Neck Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel;
2
 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3 Division of Thoracic Surgery, Department of Cardiothoracic
Surgery, Rabin Medical Center – Beilinson Hospital, Petach Tikva, Israel


SUMMARY
Objective. Partial or total sternotomy is required for 10% of retrosternal goiter. This study
reviewed our experience with an extended cervicotomic approach as an alternative surgical
solution for retrosternal goiter.
Methods. A retrospective study was performed on patients who underwent partial or total
thyroidectomy for retrosternal goiter between 2014 and 2019 at a tertiary medical centre.
Data on clinical, radiologic, and pathologic factors were analysed. Peri- and postoperative
outcomes were compared between extended and standard cervical approaches to predict the
need for an extended cervical approach.
Results. The cohort included 265 patients, of whom 245 (92.4%) were treated by standard
thyroidectomy. In 17 (6.4%), the standard approach proved insufficient, and the horizontal in-
cision was extended to a T-shape to improve access. The remaining 3 patients required a ster-
notomy. Use of the extended cervical approach was significantly associated with clinical fea-
tures such as male gender, diabetes, high body mass index and postoperative hypocalcaemia.
Conclusions. The extended cervicotomic approach is an alternative surgical solution for
retrosternal goiter, with no increased risk of significant post-operative complications.
KEY WORDS: retrosternal goiter, cervicotomy, hypoparathyroidism, extended approach,
sternotomy



Introduction                                                                                     Received: September 6, 2023
Some authors 1 define a thyroid goiter as retrosternal if it descends with its in-               Accepted: October 17, 2023
ferior lobes below the thoracic inlet plane, while others 2,3 use such a definition
                                                                                                 Correspondence
when more than 50% of its mass lies inferior to the thoracic inlet. The inci-                    Nir Tsur
dence of retrosternal extension of thyroid goiters may therefore range greatly                   E-mail: nirtsur19@gmail.com
between 2.6% and 30.4% 4-7 according to the definition used. Causes include
various genetic and environmental factors 8.                                                       How to cite this article: Tsur N, Levi L, Frig
Surgery is indicated for retrosternal goiter in the presence of compression symp-                  O, et al. Extended cervical approach for ret-
                                                                                                   rosternal multinodular goiter. Acta Otorhi-
toms or potential airway compromise and to treat thyroid malignancy. Thyroid-                      nolaryngol Ital 2024;44:21-26. https://doi.
ectomy can usually be safely performed via a standard cervical incision. How-                      org/10.14639/0392-100X-N2746
ever, if the gland is too large, median sternotomy may be necessary to gain safe
                                                                                                 © Società Italiana di Otorinolaringoiatria
access. Compared to cervical incision, both complete and partial sternotomies                    e Chirurgia Cervico-Facciale
are associated with a high incidence of morbidity and prolonged hospitalisation,
and it can be performed only in centres with a thoracic surgeon 9-11.                                           OPEN ACCESS
Patients scheduled for thyroid surgery undergo pre-operative computerised                        This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
tomography (CT) scan to assess mediastinal extension. Several classification                     Commercial-NoDerivatives 4.0 International) license. The
systems have been developed to identify patients requiring an extra-cervical                     article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
approach such as sternotomy 12-15 based on the craniocaudal length of the me-                    only in the original version. For further information: https://
diastinal extension, the anterior or posterior extension, and the relationship                   creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                           21
N. Tsur et al.




between the substernal thyroid and major mediastinal ves-
sels and trachea.
The present study aimed to describe our experience with using
an extended cervical surgical approach for retrosternal multi-
nodular goiters that were not amenable to safe removal by the
standard approach, thus avoiding the need for partial or com-
plete sternotomy. In addition, we sought to identify clinical,
radiologic, and pathological factors associated with the need
for an extended cervical approach and to compare outcomes
and complications with the standard cervical approach.

                                                                 Figure 1. The extended cervical approach; a transverse collar and a midline
Materials and methods                                            incision to the sternal notch.
The healthcare database of a tertiary university-affiliated
medical centre was retrospectively searched for patients who     ic@ NIM response 3.0) was used in all cases. Afterward,
underwent thyroidectomy for a retrosternal goiter from 2014      upward gland delivery was attempted using the index and
to 2019. Data were collected from the computerised medical       middle finger. If this manoeuver failed, we extended the
records and surgical and pathology reports as follows:           approach by making a midline incision from the sternal
• pre-operative - history, physical examination, standard        notch to the lower border of the cricoid cartilage (Fig. 1). If
   laboratory parameters including thyroid function and cal-     thyroidectomy still could not be accomplished, the thoracic
   cium level, and radiological studies such as neck ultra-      surgeon performed partial or complete sternotomy.
   sound and chest CT;
• intra-operative - operative time, surgical approach            Pathology
   (standard cervical, extended cervical, or sternotomy);        The pathological analyses were performed by the Institute of
• post-operative - length of in-hospital stay, complications.    Pathology at our medical centre. Thyroid gland measurements
The study was approved by the institutional ethics board of      were determined, including weight, length, width, and depth.
Rabin Medical Center (RMC 2020-903) and was reported             In addition, specimens were routinely sampled for malignancy.
according to the STROBE 16 guidelines.
                                                                 Data analysis
Radiology                                                        Statistical analyses were performed using SPSS version 25.
Retrosternal goiter was diagnosed by routine CT, ultra-          Continuous data are presented as mean and inter-quartile
sound, or intra-operative assessment of the thyroid if more      range or mean and standard deviation, and categorical data
than 50% of the gland lay inferior to the thoracic inlet 2,3.    are presented as numbers and percentages where appropriate.
Pre-operative CT scans were analysed by head and neck ra-        Continuous data were compared between groups using Mann-
diologists and focused on the maximal retrosternal area of       Whitney U-test, and categorical data, using Fisher exact test.
the goiter, three-dimensional lobe measurements, texture,        A p value of < 0.05 was considered statistically significant.
calcifications, and relation of the goiter to the trachea, oe-
sophagus and major mediastinal vessels. If clinical or sono-
graphic findings were suspicious for thyroid malignancy, a
                                                                 Results
fine-needle aspiration biopsy was performed 12.                  The cohort consisted of 265 patients with retrosternal goiter
                                                                 who underwent total or partial thyroidectomy during the study
Surgical technique                                               period. Standard cervical thyroidectomy (SC group) was per-
The operative procedure started with neck exploration            formed in 245 patients (92.4%) and extended cervical thyroid-
through a Kocher transverse collar incision from the medi-       ectomy (EC group) in 17 patients (6.4%). The remaining three
al border of one sternocleidomastoid muscle to the medial        patients (1.2%) ultimately required sternotomy (Tab. I).
border of the other, after stretching the strap muscles or di-   Table I shows the demographic, clinical, and laboratory data.
viding the sternothyroid muscle when necessary. The upper        Compared to the SC group, the EC group had a significantly
thyroid pedicles were then exposed, ligated, and transect-       higher proportion of males (58.8 vs 23.6%, p = 0.003), higher
ed. The recurrent laryngeal nerve (RLN) and parathyroid          mean age (61.7 vs 55.8 years, p = 0.099), higher mean body
glands were identified and preserved. A neural integrity         mass index (BMI) (31.9 vs 28.6, p = 0.008), and a higher rate
monitor (NIM) electromyogram tracheal tube (Medtron-             of diabetes mellitus (47.1 vs 15.1%, p = 0.003). After logistic



22
                                                                                                                                    Extended cervicotomy in retrosternal goiter




regression analysis, the differences in gender and diabetes                                   by a longer mean operative time than the SC group (2.4 vs 1.9
remained statistically significant.                                                           hours, p = 0.023), in addition to a longer mean hospital stay
There were no significant differences in cytologic findings.                                  (6.1 vs 4.8 days, p = 0.0002) and a higher rate of postoperative
Overall, CT scan data were available for 177 patients (68%):                                  transient hypocalcaemia (11.8 vs 1.2%, p = 0.04) (Tab. III).
164 (66.9%) in the SC group and 13 (76.4%) in the EC group.                                   Significantly higher values of the following parameters
The factors that strongly correlated with the extended ap-                                    were recorded in the EC group: mean left lobe weight
proach were the descent of the retrosternal goiter below the                                  (152.7 vs 67.8 gr, p = 0.0026), height (8.9 vs 7.2 cm,
carina (47 vs 11.4%, p = 0.014) and the brachiocephalic vein                                  p = 0.0025), depth (4.3 vs 3.2 cm, p = 0.016), and volume
(35.2 vs 8.5%, p = 0.036). There were no significant differenc-                               (290.4 vs 145.6 cm3, p = 0.035) (Tab. III).
es in other radiologic parameters, including extension below                                  Three patients (1 male, two females) underwent thyroidec-
the anterior mediastinum and aortic arch, tracheal dislocation,                               tomy by a sternotomy approach (2 manubriotomy, 1 complete
and compression (Tab. II). The EC group was characterised                                     sternotomy). Their mean age was 70 years (range 64-82), and


Table I. Demographic, clinical and laboratory data of patients undergoing thyroidectomy for retrosternal goiter.
                                                                                    Standard cervical            Extended cervical (N=17)                                p value
                                                                                        (N = 245)
 Demographics                                            Male                                      58 (23.67%)                           10 (58.82%)                      0.003
                                                        Female                                     187 (76.33%)                           7 (41.18%)
                                                       Age (years)                                 55.8 (23-86)                         61.65 (47-84)                     0.099
                                          Ethnic origin               Ethiopian                     15 (6.12%)                             1 (5.88%)                        1
                                                                     Caucasian                      30 (12.24%)                            1 (5.88%)                      0.702
                                                                        Arab                        64 (26.12%)                           7 (41.18%)                      0.256
 Past medical history                               Diabetes mellitus                                37 (15.1%)                           8 (47.06%)                      0.003
                                                Ischaemic heart disease                               9 (3.67%)                           2 (11.76%)                      0.154
                                                     Dyslipidaemia                                  53 (21.63%)                            1 (5.88%)                       0.21
                                                   Pulmonary disease                                 17 (6.94%)                           2 (11.76%)                      0.354
                                                      Hypertension                                  72 (29.39%)                           9 (52.94%)                      0.056
                                                         Smoker                                     50 (20.41%)                           7 (41.18%)                      0.064
 Symptoms                                             Voice change                                   17 (6.94%)                           2 (11.76%)                      0.369
                                                         Cough                                       11 (4.49%)                            1 (5.88%)                       0.57
                                                         Stridor                                           0                               1 (5.88%)                      0.065
                                                      Odynophagia                                     7 (2.86%)                           2 (11.76%)                      0.109
                                                       Dysphagia                                    62 (25.31%)                          4 (23.53%)                         1
                                                       Dyspnoea                                     69 (28.16%)                          5 (24.41%)                         1
                                                      Orthopnoea                                     21 (8.57%)                               0                           0.375
                                              Restricted cervical mobility                            5 (2.04%)                          2 (11.76%)                       0.069
                                                      Cervicalgia                                    17 (6.94%)                           1 (5.88%)                         1
                                                      Neck mass                                     35 (14.29%)                          4 (23.53%)                       0.295
 Physical examination                          Body Mass Index (kg/m2)                                  28.57                        31.92 (23.46-40.6)                   0.008
                                                                                                   (17.58-48.61)
 Laboratory results                               Preop TSH (mIU/L)                                 1.59 (0-18)                       1.85 (0.01-12.3)                    0.709
                                                 Preop free T3 (ng/dL)                             4.1 (1.12-13)                       3.73 (1.9-6.2)                      0.54
                                                 Preop free T4 (ng/dL)                            14.65 (0.9-34)                     13.09 (10.2-15.6)                    0.074
                                                Preop calcium (mg/dL)                            8.33 (9.32-11.6)                    9.46 (8.57-10.66)                    0.248
                                                   Preop Tg (ng/mL)                             353.34 (0.2-2659)                      285 (153-417)                       0.58
                                                 Preop anti-Tg (IU/mL)                          79.31 (0.01-827)                    6381.51 (0.01-8669)                   0.275
                                                Preop anti-TPO (IU/mL)                         279.43 (0.02-7876)                   1255.48 (0.02-8669)                   0.461
Tg: thyroglobulin; TPO: thyroid peroxidase; TSH: thyroid stimulating hormone; ng/dL nanograms per deciliter of blood; mIU/L million international units per liter; mg/dL milligram per
deciliter of blood; IU/mL international units per mililiter; values given as number and percentage or mean and range.




                                                                                                                                                                                   23
N. Tsur et al.




Table II. Comparison of pre-operative imaging features between patients with retrosternal goiter treated by standard or extended cervical approach.
                                                                                 Standard cervical                 Extended cervical             p value
 Dominant enlarged lobe                            Right                            88 (35.92%)                       7 (41.18%)                 0.939
                                                    Left                              98 (40%)                       8 (47.06%)
                                                    Both                             18 (7.35%)                       1 (5.88%)
 Descent of the goiter                     Anterior mediastinum                     89 (36.33%)                      11 (64.71%)                 0.457
                                                   Carina                           28 (11.43%)                       8 (47.06%)                 0.014
                                            Brachiocephalic vein                     21 (8.57%)                       6 (35.29%)                 0.036
                                                Aortic arch                          10 (4.08%)                      3 (17.65%)                  0.13
 CT measurements                         Length             ≥ 10 cm                 47 (19.18%)                      3 (17.65%)                    1
                                                            < 10 cm                  13 (5.31%)                       1 (5.88%)
                                         Width              ≥ 5 cm                   37 (15.1%)                      6 (35.29%)                  0.752
                                                            < 5 cm                  42 (17.14%)                      5 (29.41%)
                                         Depth               ≥ 5 cm                 43 (17.55%)                       6 (35.29%)                 0.706
                                                             < 5 cm                  24 (9.8%)                        2 (11.76%)
 Tracheal dislocation                                Yes                           115 (46.94%)                      11 (64.71%)                 0.36
                                                     No                             19 (7.76%)                             0
 Tracheal pressure                                   Yes                            86 (35.1%)                        8 (47.06%)                 0.498
                                                     No                            44 (17.96%)                        2 (11.76%)
 Calcifications                                      Yes                           68 (27.76%)                        5 (29.41%)                   1
                                                     No                             19 (7.76%)                        1 (5.88%)
 Texture                                        Homogeneous                          4 (1.63%)                             0                       1
                                               Heterogeneous                       96 (39.18%)                       10 (58.52%)
 Density                                         Hypodense                         82 (33.47%)                       4 (23.53%)                  0.366
                                           Isodense or hyperdense                    7 (2.86%)                        1 (5.88%)
Values given as number and percentage.


their mean BMI was 28.9 (range, 28.1-29.8). Two of them                         parameters, we found that male sex, high BMI, and presence
had pre-operative CT scans. The goiter descended below the                      of diabetes were associated with a more frequent need for an
carina and the brachiocephalic vein in one patient. In the re-                  extended cervical approach. In addition, in previous studies in-
maining two patients, the goiter extended below the level of                    vestigating potential predictive clinical factors for sternotomy
the carina and the brachiocephalic vein, reaching into the an-                  in goitrous thyroids, dysphonia, stridor, and other compressive
terior mediastinum. One patient showed tracheal dislocation                     symptoms 19 were shown to increase such a risk. However,
and compression in pre-operative imaging studies.                               these characteristics were not significant in our study because
                                                                                our cohort was composed almost entirely of patients treated
Discussion                                                                      by a transcervical approach (standard or extended). Further-
                                                                                more, most articles addressed the pre-operative laryngeal as-
There is considerable controversy regarding the appropriate                     sessment 20, whereas we are the first to include BMI and neck
surgical approach for retrosternal goiter 14,17. The standard                   mobility as potential predictive factors for the comprehensive
cervical approach is sufficient for proper exposure in about                    cervical approach. This is important because during surgery
90% of patients; the remainder usually undergo median ster-                     for retrosternal goiter, a significant amount of cervical exten-
notomy 15,18. In this study, we describe an alternative extended                sion is needed to expose the thyroid gland and excise the mass,
cervical approach to retrosternal goiter that might avoid in se-                and both high BMI and neck rigidity with reduced extension
lected cases the need for sternotomy. The technique involves                    are limiting factors in this setting. Thus, patients with these
extending the standard horizontal incision with a vertical tract                features would more frequently require an extended cervical
to form a T-shape, thereby improving the exposure of the tho-                   or trans-sternal approach.
racic inlet structures, strap muscles along the sternal edge, and               CT or MRI is essential to define the relevant anatomical struc-
the anterior mediastinal component of the thyroid gland with-                   tures in the surgical field and determine the most adequate
out sternotomy morbidity. On analysis of the pre-operative                      surgical approach 21,22. In the present study, there was a sig-



24
                                                                                                                               Extended cervicotomy in retrosternal goiter




Table III. Comparison of post-operative complications and pathology between patients with retrosternal goiter treated by the standard or extended cervical approach.
                                                                                      Standard cervical                 Extended cervical              p value
 Post-operative                         Duration of operation (hours)                            1.94 (0-5.48)                      2.4 (0.98-3.97)          0.023
 complications                           Hospitalisation period (days)                            4.83 (1-12)                          6.12 (5-9)            0.0002
                                                  Haematoma                                       14 (5.71%)                                X                0.609
                                         Unilateral RLN paresis- Total                            21 (8.57%)                          2 (11.76%)              0.656
                                      Unilateral RLN paresis- Temporary                            9 (3.67%)                           1 (5.88%)              0.495
                                     Unilateral RLN paresis- Permanent                            12 (4.89%)                           1 (5.88%)              0.591
                                         Amount in drain POD 1 (ml)                             56.32 (10-230)                      59.55 (20-145)            0654
                                        Maximal amount in drain (ml)                            66.95 (10-250)                       67.5 (30-145)            0.686
                                     Calcium                        POD 1                       9.02 (5.7-10.2)                      8.74 (8.1-9.2)           0.152
                                                                    POD 3                      9.01 (7.28-10.19)                    7.41 (5.62-9.2)           0.357
                                                                   POD 30                       8.99 (6.7-10.4)                      8.71 (6.5-9.9)           0.536
                                       Temporary hypoparathyroidism                                3 (1.22%)                          2 (11.76%)               0.04
                                       Permanent hypoparathyroidsim                                9 (3.67%)                           1 (5.88%)              0.495
 Pathology                                      Total weight (gr)                              161.13 (15.5-430)                    181.2 (38-484)            0.814
                                    Right lobe                    Weight (gr)                    72.39 (4-490)                       99.2 (12-313)            0.302
                                                                  Height (cm)                    6.98 (0.8-15)                       8.35 (4.5-15)            0.231
                                                                  Width (cm)                      4.6 (0.8-11)                         4.81 (3-8)             0.663
                                                                  Depth (cm)                      3.38 (0.5-8)                         3.95 (2-7.5)           0.207
                                                                 Volume (cm3)                150.32 (0.51-843.75)                   223.48 (27-900)          0.356
                                     Left lobe                    Weight (gr)                   67.77 (42-340)                      152.75 (26-475)          0.0026
                                                                  Height (cm)                    7.2 (2.2-75)                        8.94 (5.5-12.5)         0.0025
                                                                  Width (cm)                     4.65 (1.5-11)                        6.11 (3-11.5)           0.093
                                                                  Depth (cm)                      3.25 (0.5-7)                          4.28 (3-6)            0.016
                                                                 Volume (cm3)                145.65 (6.16-918.75)                  290.4 (49.5-862.5)        0.035
                                                  Malignancy                                     80 (32.65%)                           2 (11.76%)            0.104
RNL: recurrent laryngeal nerve; POD: post-operative day. Values given as number and percentage or mean and Inter-quantile range.




nificant difference between the EC and SC groups in terms of                              goiters that cannot be accessed through the standard cervi-
extension of the thyroid lobe to the carina and brachiocephalic                           cal approach without any clinically significant increase in
vessels during imaging.                                                                   terms of complication rates.
On post-operative pathological examination, the height of the                             Only 3 patients in our series ultimately required median ster-
thyroid lobe was a significant factor determining the use of                              notomy. They were characterised by older age and comorbidi-
the extended cervical approach. This finding is in agreement                              ties such as diabetes mellitus and hypertension. In all cases, the
with the literature 23. Not unexpectedly, the surgery duration,                           radiological findings, including the extension of the goiter to the
hospitalisation time, and rate of transient hypocalcaemia were                            thoracic inlet showed tracheal dislocation and compression 13.
higher in the EC than in the SC group. Extended surgery was                               These findings are in concordance with the literature on sternot-
not associated with higher rates of intra- and post-operative                             omy 13, but have not previously been assessed for extended cer-
complications than traditional surgery. Previous studies have                             vical surgery. Furthermore, the sternotomy group, as expected,
found sternotomy to be associated with increased rates of                                 had a relatively long operative time and increased hospital stay.
critical postoperative morbidities, including bleeding requir-                            Although the sternotomy group was too small to provide statis-
ing transfusion, unplanned intubation, longer post-operative                              tical insights, these findings also agree with the literature 7,9,27.
hospitalisation, and potentially higher overall mortality 24,25.                          Our study has several limitations. First, we used a retro-
Thus, with an equivalent retrosternal extension, a transcer-                              spective, non-randomised design which has known inher-
vical approach should be attempted whenever anatomically                                  ent biases. Second, the intraoperative decision-making was
possible, regardless of pathology 26. Herein, we describe                                 heterogeneous because surgeons with different levels of
a novel approach for treating retrosternal multinodular                                   expertise performed the operations.



                                                                                                                                                                      25
N. Tsur et al.




Conclusions                                                                              8
                                                                                              Sorensen JR, Bonnema SJ, Godballe C, et al. The impact of goiter and thyroid
                                                                                              surgery on goiter related esophageal dysfunction. A systematic review. Front
Extended cervical thyroidectomy is an alternative surgical                                    Endocrinol 2018;9:679. https://doi.org/10.3389/fendo.2018.00679
                                                                                         9
                                                                                              Abboud B, Sleilaty G, Mallak N, et al. Morbidity and mortality of thyroid-
solution for retrosternal goiter and is not associated with a                                 ectomy for substernal goiter. Head Neck 2010;32:744-749. https://doi.
significant increase in postoperative complications com-                                      org/10.1002/hed.21246
pared to the standard cervicotomic approach. This approach                               10
                                                                                              Bateman RM, Sharpe MD, Jagger JE, et al. 36th International Sympo-
may be safely used to avoid sternotomy in patients with large                                 sium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-
                                                                                              18 March 2016. Crit Care 2016;20(Suppl 2):94. https://doi.org/10.1186/
retrosternal goiters. Further large-scale research is needed to                               s13054-016-1208-6
identify the unique characteristics of patients requiring ster-                          11
                                                                                              Piazza C, Duranti L, Giannini L. The transmanubrial osteomuscular-spar-
notomy compared to an extended cervical approach.                                             ing approach: a valuable adjunct to the head and neck surgical armamen-
                                                                                              tarium. Curr Opin Otolaryngol Head Neck Surg 2020;28:61-67. https://doi.
                                                                                              org/10.1097/MOO.0000000000000605
Conflict of interest statement                                                           12
                                                                                              Malvemyr P, Liljeberg N, Hellström M, et al. Computed tomography for
The authors declare no conflict of interest.                                                  preoperative evaluation of need for sternotomy in surgery for retrosternal
                                                                                              goitre. Langenbecks Arch Surg 2015;400:293-299. https://doi.org/10.1007/
                                                                                              s00423-014-1268-5
Funding                                                                                  13
                                                                                              Grainger J, Saravanappa N, D’Souza A, et al. The surgical approach to retros-
This research did not receive any specific grant from funding                                 ternal goiters: the role of computerized tomography. Otolaryngol Head Neck
                                                                                              Surg 2005;132:849-851. https://doi.org/10.1016/j.otohns.2005.01.039
agencies in the public, commercial, or not-for-profit sectors.                           14
                                                                                              Gharib H, Goellner JR. Fine-needle aspiration biopsy of the thy-
                                                                                              roid: an appraisal. Ann Intern Med 1993;118:282-289. https://doi.
Author contributions                                                                          org/10.7326/0003-4819-118-4-199302150-00007
NT, AM, GB, TS: conceived and designed the study; OF,                                    15
                                                                                              Rugiu M, Piemonte M. Surgical approach to retrosternal goitre: do we still
                                                                                              need sternotomy? Acta Otorhinolaryngol Ital 2009;29:331-338.
NK: provided statistical advice on study design and ana-                                 16
                                                                                              Cuschieri S. The STROBE guidelines. Saudi J Anaesth 2019;13:S31-S34.
lyzed the data; LL, OW: drafted the manuscript, and all                                       https://doi.org/10.4103/sja.SJA_543_18
authors contributed substantially to its revision; NT: takes                             17
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responsibility for the paper as a whole.                                                      https://doi.org/10.1002/jso.2930600313
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                                                                                              notomy required? J Surg Res 2015;199:121-125. https://doi.org/10.1016/j.
Ethical consideration                                                                         jss.2015.04.045
This study was approved by the Institutional Ethics Com-                                 19
                                                                                              Stang MT, Armstrong MJ, Ogilvie JB, et al. Positional dyspnea and tracheal
mittee (Rabin Medical Center) (protocol number: IRB-                                          compression as indications for goiter resection. Arch Surg 2012;147:621-626.
RMC 2020-903).                                                                                https://doi.org/10.1001/archsurg.2012.96
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                                                                                              Shen WT. Predictors of airway complications after thyroidectomy for
The research was conducted ethically, with all study proce-                                   substernal goiter. Arch Surg 2004;139:656-660. https://doi.org/10.1001/
dures being performed in accordance with the requirements                                     archsurg.139.6.656
of the World Medical Association’s Declaration of Helsinki.                              21
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Written informed consent was obtained from each partici-                                      ceived voice changes and quantitative voice measures in the first postopera-
                                                                                              tive year after thyroidectomy a secondary analysis of a randomized clinical
pant/patient for study participation and data publication.                                    trial. JAMA Otolaryngol Head Neck Surg 2018;144:995-1003. https://doi.
                                                                                              org/10.1001/jamaoto.2018.0309
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