Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Objectives: To determine the relationship of aerodigestive symptoms with demographics, pathology, and severity of anatomical factors in patients with substernal goiters
Methods: Adult subjects with substernal goiters surgically treated from January 2013 to July 2024 at a large academic medical center were retrospectively reviewed. A substernal goiter was defined as a thyroid mass extending below the clavicles verified by computed tomography (CT) imaging. Tracheal deviation (TD) and compression (TC) were measured using axial CT scans of the neck. Severe TD and TC were defined using median values. Substernal extension and laterality were defined by location on coronal CT. Aerodigestive symptoms included dysphagia, dyspnea, dysphonia, and coughing. Chi-squared, Mann-Whitney U test, and paired t-tests were used to evaluate the correlation between symptoms and anatomical measurements, demographics, and pathology data. Spearman rank correlation was then used to determine the direction of association for statistically significant results as appropriate.
Results: A total of 201 subjects were included. The most common presenting symptom was dysphagia (48.8%) followed by dyspnea (40.3%). The average measurement of TD was 12.2 mm (0-37) and average TC was 32.7% (0-80%). Neither goiter depth nor presence of TD had a significant association with any individual symptom. Patients with TC were significantly more likely to present with dyspnea (p< 0.001), and even more so in those with severe TC (p< 0.001). Higher specimen weight also significantly corresponded with presence of dyspnea (p=0.013). Pathology class was significantly associated with dyspnea, coughing and the lack of symptoms at presentation. Further analysis revealed a weakly negative correlation between dyspnea and dysphagia with more aggressive pathology, and a weakly positive correlation between dysphonia and the lack of symptoms with more aggressive pathology. Those with TC and a visible mass on presentation were more likely to have more pre-operative symptoms (p=0.02, 0.05 respectively). The average BMI was 34.4 kg/m2 (19.3-78.1), and average age was 55.4 years (20-88), neither of which had any significant association with any aerodigestive symptoms.
Conclusions: Patients with substernal goiter present in a variety of ways. Patients with severe tracheal compression and a larger goiter weight are more likely to present with dyspnea, however no other anatomical or demographic factors were noted to correlate with symptoms. Those with dyspnea and dysphagia may be more likely to have a less aggressive pathology, however dysphonia and a complete lack of symptoms should raise suspicion for a more aggressive diagnosis. Though use of pre-operative CT scan is not standard in workup of substernal goiter, its use can provide valuable information about the severity of the disease process that may otherwise be indolent on presentation.