Multinodular goiter (MNG) is the most common surgical thyroid pathology. It may grow directly into the mediastinum or, rarely, there may be ectopic tissue.

42-year-old woman, with no previous history, referred for endocrine surgery, coming from another hospital, due to increased cervical perimeter and dyspnea.

On ultrasound, a 5cm mixed isoechoic nodule was identified on the right thyroid lobe, with no nodules on the left. Analytically she had a subclinical hyperthyroidism and increased anti-thyroglobulin antibodies. She had been submitted to a fine needle aspiration biopsy who excluded malignancy. The CT scan showed an exuberant growth of the right lobe towards the mediastinum extending until the pulmonary hilum. The nodule shaped the carina, right bronchus, superior vena cava and thoracic aorta, measuring 8.9x8.6cm. We performed a scintigraphy, which only captured the right lobe nodule. After discussion, the patient decided right lobectomy with isthmectomy rather than total thyroidectomy. Intraoperatively, with aspiration of the cystic component, there was no need for sternotomy. No complications were recorded and was discharged ate second day after surgery. Histological exam revealed nodular disease of thyroid follicular cells with lymphocytic thyroiditis. Nowadays, the patient is euthyroid, asymptomatic and under surveillance.

Despite the possibility of sternotomy, 95% of MNG with a component extending into the mediastinum can be removed through a cervical incision. The decision of the extension of surgery should be discussed with the patient, explaning the risks and the benefits of each option, on a case-by-case basis.