Untreated Goiters Larger at Surgery in Men, Minorities, and the Old

Pam Harrison

March 14, 2016

Significant disparities exist in the presentation and outcomes of patients with goiters in the United States, with minority ethnic groups, men, and older patients more likely to present with untreated goiters that have become so large they extend into the chest, meaning they are more difficult to remove, a nationally representative analysis shows.

Senior author Alliric Willis, MD, from Thomas Jefferson University, Philadelphia, Pennsylvania, said: "My initial interest in this topic stemmed from my experience with taking care of my own patients with this condition in that there appeared to be a preponderance of patients who were…late in presenting."

"So we wanted to determine whether this was indeed the case nationally as well as whether there were any deleterious effects [from late presentation], and we found significant disparities in substernal thyroidectomy...and increased risks associated with this operation in comparison with nonsubsternal goiter operations," Dr Willis, told Medscape Medical News.

The study is the first to report such disparities in untreated goiters and was published online in the American Journal of Surgery.

Blacks, Hispanics, Elderly, and Males More Likely to Avoid Treatment

A goiter is an enlargement of the thyroid gland in the neck, and in much of the world goiters are caused by a lack of iodine, but in the United States, where salt is enriched with iodine, they tend to develop due to a number of factors, which may include an overactive thyroid (Graves' disease), an underactive thyroid (Hashimoto's disease), family history, or differences in anatomy.

Substernal goiters grow slowly but steadily over time, extending below the clavicles into the upper chest, and there are a number of associated signs and symptoms, including dyspnea, dysphagia, hyperthyroidism, hoarseness, the sensation of a mass in the throat, superior vena cava syndrome, and chylothorax due to thoracic duct compression. But sometimes there are no symptoms at all.

In this study, led by Ambria Moten, MD, Temple University School of Medicine, Philadelphia, Pennsylvania, investigators set out to compare patients undergoing thyroidectomy for substernal vs nonsubsternal goiters in the United States. They looked for any disparities in risk factors, complications, and outcomes after surgery. All patients were registered with the National Inpatient Sample database.

A total of 110,889 patients were included in the analysis, the great majority of whom had undergone nonsubsternal thyroidectomy (5525 substernal and 105,364 nonsubsternal).

Patients who had a substernal thyroidectomy were on average significantly older, by 6 years, than those who underwent a thyroidectomy for nonsubsternal goiter (57.8 vs 51.9 years; P < .0001).

More black patients, at 19.1%, were also candidates for substernal thyroidectomy than a nonsubsternal procedure at 12.4%, (P < .0001), the study authors note.

After adjustment for multiple confounding factors, black patients were 78% more likely and Hispanic patients 19% more likely to undergo substernal thyroidectomy compared with white patients.

In contrast, Asian patients were 18% less likely to undergo a substernal procedure compared with white patients, while females were 14% less likely than males to be candidates for a substernal approach.

More Medicare patients had substernal thyroidectomy — 37.6% compared with 24.1% for those who were treated for nonsubsternal goiter.

Substernal thyroidectomy patients were also less frequently privately insured, at 49.9% vs 62.7% for nonsubsternal thyroidectomy recipients, respectively (P < .0001).

And regarding age, for each year of increase in patient age, there was a 2.4% increase in the odds of having a substernal goiter thyroidectomy.

Patients who underwent substernal thyroidectomy were also more likely to require emergency admission, stay longer in the hospital, and have a higher comorbidity index than those who underwent nonsubsternal thyroidectomy. Comorbidities included hypertension, diabetes and obesity.

Hospital and Patient Characteristics for Substernal vs Nonsubsternal Thyroidectomy Patients

Thyroidectomy type

Emergency admission (%)

Length of hospital stay (d)

Average comorbidity illness index (Elixhauser)









All P < .0001

Substernal Surgery Associated With More Complications

The researchers calculated patient safety indicators for the different groups and found significant disparities: for example, the risk of hemorrhage or hematoma following a substernal procedure was 77% higher than it was following a nonsubsternal thyroidectomy.

Respiratory failure rates were also 2.2-fold higher for those who underwent a substernal procedure, while the risk of developing a pulmonary embolism or deep venous thrombosis was 2.6-fold higher in the same group.

And substernal thyroidectomy candidates had a 4.4-fold higher risk of developing a pneumothorax following the procedure and a 69% higher risk for accidental puncture than their nonsubsternal counterparts.

Importantly, as well, substernal patients were 73% more likely to die during hospital admission than nonsubsternal patients.

"Reasons for the increased risk of complications and death may be due to the increased complexity of surgery associated with substernal goiters," said Dr Willis.

Large Untreated Goiters

Asked to explain why minorities, men, and older patients were more likely to present with large untreated goiters, Dr Willis said there are a number of possible explanations.

"When we look at minority patients, we have to appreciate the fact that there continues to be a discrepancy in access to medical treatment," he explained.

And whether this is because minorities can't afford the treatment or they are afraid of a system that hasn't always catered well to certain ethnic groups remains to be determined, he added.

As for men, it's not uncommon for males to just avoid medical care, Dr Willis observed.

Either that, "or men will think they simply have this large Adam's apple and they've either grown a beard to cover it or have just stopping looking at it and avoided care until they have significant compression symptoms related to the goiter," he said.

And the fact that older people are also prone to present with large substernal goiters highlights the fact that affected patients may have neglected their growing goiter for years until it extended into the chest, causing severe symptoms.

To redress these disparities, Dr. Willis feels the problem needs to be approached from a number of different angles.

"The primary-care physician has to recognize that if a goiter is increasing in size, this needs to be addressed, and they can do this by simply asking patients if they have noticed the nodule has increased in size over the years and then refer the patient to a surgeon," he suggested.

Furthermore, on physical examination, "if a physician cannot easily distinguish the inferior aspect of the goiter before they hit the clavicles, then patients need to be referred for further radiology evaluation or to a surgeon for evaluation," Dr. Willis added.

Earlier identification and treatment of goiters may allow earlier interventions at a stage when risks are reduced, he and his colleagues point out.

"Finally," he said, "there may be some fear that patients have about the surgery, so it's important to try to help them overcome their fear and let them know that yes, this is something that should be addressed."

The study was funded by the National Institutes of Health. The authors declare no relevant financial relationships.

Am J Surg. Published online January 6, 2016. Abstract


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