There is no standard definition for thyroid glands extending below the thoracic inlet, and there are no clear guidelines for pre-operatively identifying those patients that may require an intrathoracic approach. We therefore reviewed the current literature in order to establish the current practices regarding the management of retrosternal goitres (RSGs), and propose a classification system to aid pre-operative planning for this important group of patients. A PubMed Medline search was conducted using the search terms 'retrosternal', 'substernal', 'intrathoracic', 'mediastinal', 'goitre' and 'goiter', resulting in 626 hits. Exclusion criteria reduced the number of papers to the 34 used for this review. A total of 34 papers totaling 2426 patients were included. Eighty-four percent of patients operated on for RSG were achieved via a cervical approach, with the remainder also requiring manubriotomy (3.1%), full sternotomy (6.6%) or thoracotomy (4%). Tracheomalacia occurred in 1% of patients and Superior Vena Cava syndrome (SVC) in 3.2%. There was a clear and highly significant association between the extent and definition of RSG and reported complications, as well as the approach used, with the incidence of tracheomalacia, SVC and need for intrathoracic approach increasing more than 10-fold in cases of RSG reaching the aortic arch. There is a clear need to establish a common standard in the definition and description of the extent of RSG. Using our findings, we propose a new, simple, 3-grade classification system of RSGs, based on their relation with the aortic arch and the right atrium.
