Halsted wrote, “The extirpation of the thyroid gland for goiter perhaps typifies better than any other operation, the supreme triumph of the surgeons art.” The normal complex anatomy of the base of the neck can be distorted in sometimes predictable but sometimes unpredictable patterns by goiter. Size, vascularity, distortion of the anatomy, substernal extension, and restrictions imposed by the bony confines of the thoracic inlet can make identification and preservation of the recurrent laryngeal nerve (RLN) and parathyroid glands challenging. A definition and classification of goiter and substernal goiter has been presented (see Table 16.1 for classification of substernal goiter).

During the physical examination, the size of the goiter must be documented as well as its consistency and the possible fixation of the mass to the laryngotracheal complex. Laryngeal landmarks including the thyroid notch, anterior cricoid arch, and trachea should be examined for deviation from the midline. Distention of the jugular veins should be noted as this implies significant jugular compression. All patients being evaluated for goiter should have an examination of the larynx given the potential for vocal cord paralysis, which may be asymptomatic. The finding of vocal cord paralysis is of extreme importance in terms of surgical planning. If during examination the caudal-most portion of the goiter cannot be identified on the physical examination, substernal extension should be considered. An axial CT scan should be strongly considered in patients who have significant regional symptoms, massive goiter, bilateral circumferential goiter, substernal extension, vocal cord paralysis, or lymphadenopathy. Thyroid function tests must be performed in all patients as subclinical
hypothyroidism is not uncommon in patients with multinodular goiter. Fine needle aspiration should be considered in all patients with a nodular goiter. However, in patients with CT and ultrasonographic findings consistent with benign goiter with a smooth margin and without lymphadenopathy who will be undergoing surgery, histologic diagnosis may be deferred to final pathology.

Patients who are elderly or are poor operative candidates after complete and thorough medical evaluation may be considered for observation or nonsurgical treatment including radioactive iodine. One must be aware of the potential occurrence of radiation thyroiditis acutely with radioactive iodine treatment for goiter and the potential for the induction of Graves disease.