https://orcid.org/0000-0002-1266-9604
Abstract
Goiter is a common benign condition that typically presents with a sensation of pressure in the neck. In a slowly growing disease, the pressure symptom may be confused with another disease causing airway obstruction, and the diagnosis becomes even more difficult if the enlarged thyroid gland is located behind the sternum and not just in the neck. We describe a case of a patient who suffered from treatment-resistant obstructive airway symptoms for years, experienced several upper and lower respiratory tract infections, and underwent repeated investigations for asthma. Eventually, a large retrosternal goiter was identified as the cause of the symptoms, which was treated surgically.
Introduction
Goiter, or benign enlargement of the thyroid gland, has become rarer with the use of iodized salt, but benign nodules that can be interpreted as goiter are found on ultrasound examination of the neck in 20%–70% of the population. In addition to iodine deficiency, the tendency for goiter to grow is influenced by possible hypothyroidism and genetic factors [1]. The tendency of goiter to grow varies from individual to individual, and in a slowly growing disease, some patients adapt to the compressive symptoms to such an extent that the condition is either not recognized or is mistaken for another disease causing airway obstruction, most commonly asthma. In this case, asthma medication does not alleviate the mechanical airway obstruction, and a sufficiently severely narrowed airway can become critically narrowed in connection with a common upper respiratory tract infection.
Case report
A 74-year-old former smoker suffered from recurrent pneumonia. The patient had experienced excessive mucus production for several years, which was worse when lying down. Dyspnea occurred during exertion and when sauna bathing. In addition, wheezing was reported. Over the years, chest radiographs were obtained repeatedly, but no findings explaining the symptoms were identified. Peak expiratory flow monitoring was performed twice. No significant bronchodilator response was observed, and the patient did not experience any benefit from the medication for the symptoms.
The patient’s shortness of breath was re-evaluated by a general practitioner in the winter of 2026. At that time, a firm resistance was palpated in the right angle of the jaw. The finding led to an ultrasound examination of the neck, where the finding was revealed to be a benign Warthin’s tumor. As an incidental finding, the ultrasound examination revealed a very large thyroid gland extending behind the sternum. The patient was referred to the vascular surgery outpatient clinic for evaluation due to the large thyroid finding. At this point, it was suspected that the thyroid enlargement might be responsible for the patient’s respiratory symptoms.
An outpatient computed tomography (CT) scan revealed a giant right thyroid lobe that extended deep into the mediastinum below the aortic arch, narrowing the trachea and esophagus (Figs 1–3). Due to the abnormal size and location of the goiter, the patient underwent urgent surgery in the cardiothoracic surgery unit. During the surgery, the patient’s right retrosternal thyroid lobe was removed through a sternotomy (Figs 4–7). Removal of the left lobe was not considered because the surgery raised suspicions of a stretch injury to the recurrent laryngeal nerve on the right, and the left lobe did not extend retrosternal or narrow the airways. The patient recovered from the surgery without problems and the previous respiratory symptoms resolved.
Sagittal CT scan of the retrosternal goiter.
Coronal CT scan of the retrosternal goiter.
Axial CT scan of the retrosternal goiter.
Photograph of the surgery for a retrosternal goiter.
Photograph of the surgery for a retrosternal goiter.
Photograph of the surgery for a retrosternal goiter.
Photograph of the resected right lobe of the goiter.
Discussion
The literature describes several cases of patients in whom a large thyroid gland has led to significant respiratory symptoms and even the need for emergency surgery [2–4]. The case we describe is unusual because of the exceptionally large size of the thyroid gland and the prolonged duration of the symptoms before diagnosis.
A goiter can be asymptomatic for years due to its slow growth. Symptoms usually consist of a sensation of pressure in the neck and, in more advanced cases, airway obstruction. The symptoms may resemble asthma or chronic obstructive pulmonary disease [4].
A large goiter can often be seen as an unusual shadow on the chest radiograph or as a narrowing of the airway. Cervical ultrasound is the primary imaging modality for the evaluation of goiter, but in retrosternal goiter, CT is the so-called gold standard for both diagnosis and surgical planning [5].
The treatment of symptomatic goiter is primarily surgical. In surgical treatment, either the entire thyroid gland or a single enlarged thyroid lobe is removed. Acute worsening of chronic airway obstruction is usually precipitated by an upper respiratory tract infection causing mucosal edema or by spontaneous intrathyroidal hemorrhage [2, 3]. The patient we describe underwent urgent surgery, but not as an emergency. In this case, progression to acute critical airway obstruction could potentially have been fatal.
Inspired by the patient case, we reviewed data on thyroid surgeries from North Karelia Central Hospital over a 10-year period. In 2016–2025, 637 thyroid surgeries were performed due to goiter, of which 18 (2.8%) were performed as an emergency due to critical airway obstruction (the patient was on a ventilator due to airway obstruction). Of all the patients operated on, 79% were women. This is in line with the prevalence of goiter. However, there was no difference in the relative prevalence of emergency surgeries between men and women (Table 1). Therefore, emergency surgery due to a goiter-related airway crisis is uncommon, but not exceptionally rare.
Thyroid surgeries performed due to goiter at North Karelia Central Hospital during 2016–2025.
| Elective surgery | Emergency surgery | |
|---|---|---|
| Total | 619 | 18 (2.8%) |
| Men | 133 | 3 (2.2%) |
| Women | 486 | 15 (3.0%) |
Values are presented as the number of patients.
Percentages in parentheses indicate the proportion of emergency surgeries within each subgroup.
Elective surgery refers to planned thyroid surgery, whereas emergency surgery refers to unplanned thyroid surgery.
The patient we describe is a ‘typical atypical case’ according to the literature – an aging man with a non-palpable thyroid gland on his neck that slowly grew in the mediastinum, narrowing the airways. The patient underwent repeated and extensive examinations in both primary care and specialized care before the diagnosis was clarified, and in the end the correct diagnosis was found as an ‘incidental finding,’ although it had been seen on chest radiographs 14 years before the diagnosis.
Conclusion
An enlarged thyroid gland or thyroid nodule is a relatively common and often harmless condition and is more commonly detected incidentally on imaging studies than as a symptomatic condition. The typical symptom of a goiter is a feeling of pressure in the neck, which may lead to airway obstruction as it develops. The treatment of symptomatic goiter is surgical.
In a slowly growing goiter or its rare form behind the sternum, the symptoms may be confused with other diseases affecting the respiratory tract. When evaluating patients with respiratory symptoms and performing differential diagnosis, mechanical obstruction should be kept in mind and clinicians should avoid anchoring bias toward more common diagnoses when there is a discrepancy between the clinical presentation and the presumed diagnosis.
Acknowledgements
Kimmo Kuosmanen – No acknowledgements.
Mari Heikkinen – No acknowledgements.
Anna Govenius – No acknowledgements.
Ville Vänni – Share holder, Osgenic Oy. Board member of Finnish Trauma Association.
Conflicts of interest
None declared.
Funding
None declared.
