Positional dyspnea and tracheal compression as indications for goiter resection.

HYPOTHESES: Goiter is a surgically reversible cause of positional dyspnea (PD). Substernal tracheal compression (TC) predicts PD relief after thyroidectomy (Tx). DESIGN: Retrospective analysis of a prospective structured management algorithm. SETTING: Endocrine surgery academic center. METHODS: Before Tx, 1081 patients were queried about PD. Those patients with substernal goiter underwent computed tomography, and their degree of TC was estimated as greatest percent reduction of transverse tracheal diameter. For 197 patients with PD, TC, or both, surgical outcomes were examined with a mean follow- up of 12.6 months. After Tx, patients who carried the diagnosis of obstructive sleep apnea were referred for repeat sleep study evaluation. RESULTS: Positional dyspnea was reported by 188 of 1081 patients, and after Tx the PD improved or resolved in 82.4%. In the 151 patients with substernal goiter, TC was present on imaging in 97.2%; the mean (range) TC was 34% (5%-90%). Patients with TC had a high likelihood of PD (93.5%). After substernal goiter resection, PD improved in stepwise association with total resected thyroid gland weight. Improvement in PD was strongly predicted by both gland weight of 100 g or more (P.001) and by TC of 35% or more (P.01). After Tx, 59 of 77 snorers (76.6%) reported improvement in snoring, 77.1% of patients with obstructive sleep apnea reported improved PD, and 2 of 3 retested patients with obstructive sleep apnea demonstrated objective improvement in sleep study apnea-hypopnea index. CONCLUSIONS: Resection of bulky goiter frequently improves PD, which in substernal goiter is highly associated with TC. Either PD or TC of 35% or more prompt Tx. Goiter should be considered when obstructive sleep apnea is diagnosed.