Intrathoracic goitre surgery: when it is necessary and how it is performed
When part of the thyroid gland grows into the chest cavity, it is common for people to have questions about treatment. Is surgery always necessary? Could it continue to grow? Is the operation performed via the neck? What will the recovery be like?
Although its location may cause concern, the decision on treatment is not based solely on the size of the goitre or the fact that it is partially behind the breastbone. The specialist must assess the symptoms, the progression of the condition, the function of the gland and, in particular, the relationship between the goitre and the trachea, oesophagus and major blood vessels.
“Not all endothoracic goitres are of the same size or have the same consequences. The decision to operate must be tailored to the anatomy, symptoms and overall condition of each patient,” explains Dr Jorge Martín Gil, head of the General and Digestive Surgery department at the Publio Cordón Memorial Hospital.
When surgery is indicated, careful planning allows the complexity of the procedure to be anticipated and the safest approach to be chosen. In most patients, surgery can be performed via a cervical incision, without the need for direct access to the chest. The most recent systematic reviews confirm that the cervical approach is sufficient in the majority of cases and that only a minority require a complementary thoracic approach.
When might it be necessary to operate on an endothoracic goitre?
Surgery is usually considered when the growth of the thyroid is causing symptoms, compressing nearby structures or exhibits characteristics that make its removal advisable.
One of the most common reasons is airway compromise. The goitre may displace the trachea or progressively reduce its diameter. Initially, the person may notice that they become more fatigued when walking briskly, climbing stairs or lying down. If the compression increases, breathing difficulties may occur with less strenuous activity and even at rest.
There may also be difficulty swallowing, a feeling of pressure at the base of the neck, a persistent cough or changes in the voice. These symptoms do not always appear suddenly. As the growth is usually slow, some people unconsciously adjust their activity levels or diet and are slow to recognise that there is a limitation.
The presence of symptoms or signs of compression on imaging tests remains one of the main reasons for recommending surgery. A systematic review published in *The Laryngoscope* concluded that these factors account for a large proportion of operations performed for endothoracic goitre, although a proportion of patients are diagnosed before experiencing clear symptoms.
Surgery may also be recommended when the goitre shows progressive growth, there is hyperthyroidism that is difficult to control, nodules appear that require a definitive diagnosis, or a malignant lesion is suspected. However, having an endothoracic goitre does not, in itself, mean that a person has cancer.
In asymptomatic individuals with stable thyroid function and no significant compression, follow-up may be considered. Age, associated conditions, anaesthetic risk and the patient’s preferences should also be taken into account in the decision-making process. The guidelines of the European Thyroid Association specifically advocate an individualised assessment of nodules and goitres, integrating clinical, laboratory and radiological findings rather than basing treatment on a single measure.
“We don’t operate solely on the basis of an image or a specific number of centimetres. We assess how that growth is affecting the person and what might happen if it continues to develop,” says Dr Martín Gil.
What tests are carried out before the operation?
Before recommending surgery, it is necessary to understand both how the gland is functioning and the anatomy of the goitre.
Blood tests allow us to check levels of thyroid hormones and TSH. If hyperthyroidism is present, it usually needs to be brought under control before the operation to reduce risks during anaesthesia and the post-operative period.
A neck ultrasound examines the thyroid tissue accessible from the neck and helps to assess the characteristics of the nodules. However, it cannot accurately visualise the entire portion located behind the breastbone.
For this reason, a CT scan of the neck and chest plays a central role in planning. It allows us to determine:
How far down the goitre extends.
Whether it displaces or narrows the trachea.
How it relates to the oesophagus and the great vessels.
Whether it occupies the anterior or posterior part of the mediastinum.
Whether there are any features that might make it difficult to remove from the neck.
A CT scan is not merely a diagnostic test. It acts as a map that enables the surgeon to plan the procedure in advance and prepare any resources that may be required. Extension into the posterior mediastinum, descent below certain anatomical levels and certain configurations of the goitre have been associated with a higher likelihood of requiring a thoracic approach.
In certain situations, a laryngoscopy may also be performed to check the mobility of the vocal cords before surgery. This is usually considered particularly when there is hoarseness, a history of thyroid surgery, a large goitre or suspected involvement of the laryngeal nerves.
“A CT scan allows us to assess the goitre’s relationship with neighbouring structures and plan the surgery before entering the operating theatre. This information is essential for choosing the safest approach,” explains Dr Jorge Martín Gil.
How is surgery for an endothoracic goitre performed?
The procedure is carried out under general anaesthesia. Its aim is to remove the thyroid tissue responsible for the growth, relieve pressure on the compressed structures and obtain a definitive histopathological diagnosis.
The usual approach involves a horizontal incision in the lower neck, similar to that used in other thyroid operations. From there, the surgeon identifies the gland and carefully mobilises the part that has descended into the chest.
Although it may seem difficult to remove a goitre located partially behind the sternum via the neck, in approximately 90–95 per cent of cases described in recent literature, the procedure can be completed using this cervical approach.
Depending on the distribution of the goitre and the condition of the rest of the gland, it may be necessary to remove a single lobe or to perform a total thyroidectomy. The decision takes into account the presence of nodules on both sides, thyroid function, the suspected diagnosis and the risk of recurrence.
During the operation, the recurrent laryngeal nerves, which control the movement of the vocal cords, are identified and protected. An attempt is also made to preserve the parathyroid glands, small structures situated next to the thyroid that regulate calcium levels.
The success of the surgery is not solely about removing the goitre. It also involves preserving the voice, maintaining calcium balance and protecting the trachea, oesophagus and nearby blood vessels.
Might a thoracic approach be necessary?
Yes, but this is a rare occurrence.
In certain patients, the size or position of the goitre means it cannot be safely manoeuvred through the cervical incision. In such cases, it may be necessary to extend access via a partial or complete sternotomy, or to use another thoracic approach.
This possibility is particularly considered when the goitre:
Extends deep into the chest.
Is situated behind the trachea or the great vessels.
Reaches the lower regions of the mediastinum.
Has a shape that makes it difficult to pass through the thoracic inlet.
There is a suspicion of invasion of neighbouring structures.
A 2024 systematic review of extracervical approaches confirmed that these routes are reserved for a select minority of patients. A subsequent review and meta-analysis identified depth and mediastinal location as important factors in predicting the need for sternotomy.
The possibility of a thoracic approach should be explained before the operation when imaging suggests it may be necessary. However, it should not be presented as the standard scenario: the majority of endothoracic goitres can be treated via the neck.
What are the risks of surgery?
Surgery for an endothoracic goitre shares potential complications with other thyroid operations, although its extent may increase the technical difficulty in some patients.
One of the risks monitored is post-operative bleeding. A haematoma in the neck can compress the airway, so the condition of the wound and breathing are carefully monitored during the first few hours.
Temporary, or less commonly permanent, changes to the voice may also occur if one of the laryngeal nerves is irritated or damaged. Some people initially experience a weaker or hoarse voice, which improves during recovery.
When a total thyroidectomy is performed, calcium levels may drop if the parathyroid glands are slow to regain function. This can cause tingling around the mouth or in the hands and, if necessary, is treated with calcium and vitamin D.
In cases of goitre where the trachea has been severely compressed over a long period, the surgical team also pays close attention to the stability of the airway following removal of the gland. However, a systematic review from 2025 found that significant weakness of the tracheal wall following surgery is uncommon.
Individual risk depends on the anatomy, size and extent of the goitre, the presence of previous interventions, and the type of surgery required. Therefore, the assessment must be personalised and should avoid both underestimating and overestimating potential complications.
What is the recovery like after the operation?
Following the operation, the patient remains under observation to monitor their breathing, voice, wound and calcium levels.
During the first few days, it is common to experience neck discomfort, tightness or some discomfort when swallowing. These symptoms usually improve gradually. Fatigue may also occur, particularly following prolonged surgery or in cases of a large goitre.
The length of the hospital stay depends on the extent of the operation and the patient’s progress. When the surgery is performed via a cervical approach and no complications arise, recovery is usually similar to that following other thyroidectomies. If it has been necessary to access the chest, the hospital stay and recovery may be longer.
After discharge, you should avoid strenuous activity for the first few days, keep the wound clean and follow the surgical team’s instructions. Your return to work will depend on the nature of your job and your individual recovery.
If the entire gland has been removed, you will need to take levothyroxine for life. This medication replaces the hormones produced by the thyroid, and the dose is adjusted through regular blood tests. When part of the gland is preserved, it may continue to function adequately, although this must also be monitored through regular check-ups.
What improvement can be expected?
Where the goitre was compressing the trachea or oesophagus, many patients notice an improvement in breathing, swallowing or the sensation of pressure following the operation.
The change may be noticeable from the very first days, although the swelling associated with the surgery may temporarily delay the perception of the result. Recovery of the voice, if there has been a temporary alteration, may also take time and require follow-up.
As well as relieving symptoms, surgery prevents a progressive goitre from continuing to take up space within the chest and allows the entire removed tissue to be examined. The histopathological examination definitively confirms the nature of the nodules, even when previous tests indicated that they were likely to be benign.
Choosing the right time
The decision to operate on an intrathoracic goitre is not based solely on the fact that part of the thyroid has descended into the chest. It is necessary to assess the symptoms it causes, how much it has grown, how it affects neighbouring structures, and what risks would be involved in adopting a ‘watch-and-wait’ approach.
When surgery is indicated, a CT scan enables the surgical approach to be planned and its complexity to be anticipated. In most patients, the procedure can be performed via a cervical incision, thereby protecting the voice, the parathyroid glands and the airway.
“Choosing the right time is just as important as performing the operation correctly. A specialist assessment helps to avoid unnecessary surgery, but also ensures intervention takes place before compression or spread makes treatment more complex,” concludes Dr Jorge Martín Gil.
In the event of severe breathing difficulties, laboured breathing, an inability to swallow or a rapid worsening of symptoms, urgent medical attention should be sought.
The information in this article is provided for general awareness and does not replace an individualised medical assessment.
