Massive retropharyngeal goiter: Case presentation and literature review of a rare entity

Abstract

Retropharyngeal goiters are uncommon entities characterized by the presence of thyroid tissue in the retropharyngeal space. We present the case of an 89-year-old female with a history of dysphagia and hoarseness of voice. Imaging revealed a massive goiter extending into the retropharyngeal and retrosternal spaces. The patient underwent a total thyroidectomy with transcervical removal of the substernal component. Our analysis of 13 documented cases (14 including ours) of retropharyngeal multinodular goiters reveals a range of presentations with dysphagia, dysphonia, and dyspnea being the most common symptoms. Total thyroidectomy emerged as the prevailing management approach, though there are surgical challenges including airway management and potential pharyngeal musculature injury. The most plausible mechanism for retropharyngeal goiter development is progressive displacement due to glandular enlargement. This case highlights the clinical considerations and perioperative strategies required for the management of retropharyngeal goiters, particularly in elderly patients with significant anatomic distortion. Additionally, we provide a comparative literature review to further characterize the presentation and surgical management of this rare entity.

Introduction

Retropharyngeal goiters are an exceptionally rare clinical entity, characterized by the aberrant extension of thyroid tissue into the retropharyngeal space. Thyroid goiters are a relatively common endocrine pathology; however, multinodular growth with retropharyngeal involvement has only been reported in 13 cases in the literature to date, with the earliest case described in 1977.^1–10 This report adds to the literature as the 14th documented case.

Diagnosing retropharyngeal goiters presents unique challenges. Their atypical location often leads to diagnostic confusion with other neck masses.^3–5 The nonspecific symptoms of retropharyngeal goiters, such as dysphagia, dysphonia, and dyspnea, overlap with a wide range of other conditions. Therefore, imaging is required in differentiating these goiters from other pathologies. Additionally, in comparison to the majority of goiters, retropharyngeal goiters can cause significant distortion of the laryngopharynx which can present unique challenges to anesthesiologists and surgeons alike.

This case report describes the presentation, diagnosis, and management of a massive retropharyngeal multinodular goiter in an 89-year-old female. Given her advanced age, additional considerations such as reduced physiologic reserve, increased risk of perioperative complications, and a higher likelihood of postoperative dysphagia were critical in tailoring her management. This report discusses these challenges alongside the clinical significance of airway management and potential injury to the pharyngeal musculature. Furthermore, a literature review is conducted to compare this case with previously documented instances, which aimed to identify emerging patterns in clinical presentation, diagnostic evaluation, and treatment strategies. This study contributes to the growing but limited understanding of retropharyngeal goiters and highlights the importance of tailored management.

Case presentation and surgical details

An 89-year-old female presented to our emergency department with dyspnea and acute respiratory failure. She was previously diagnosed with hyperthyroidism managed with methimazole and had a long-standing history of a multinodular goiter first identified over 10 years ago. She also reported progressive dysphagia, which has worsened significantly in recent years. Clinical details and diagnostic findings are summarized in the table below (Table 1).

Table 1.

Summary of the patient’s clinical features and diagnostic findings.

Key feature	Details
Age and gender	89-year-old female
Presenting complaint	Dyspnea, acute respiratory failure
Relevant history	Hyperthyroidism (managed with methimazole)
	Multinodular goiter (diagnosed in 2011)
	Progressive dysphagia (worsened over several years)
Imaging findings	Massive goiter with superior extension into retropharyngeal space
	Substernal extension to the carina
	Significant tracheal compression
Initial differential diagnosis	Thyroid malignancy, compressive goiter
Biopsy results	Benign thyroid tissue with no malignancy
Management	Intubation, mechanical ventilation, surgical intervention for tracheal compression

Initial assessment suggested a congestive heart failure exacerbation, and she was intubated and placed on mechanical ventilation. Imaging revealed a massive goiter with retropharyngeal extension, substernal extension to the carina, and severe tracheal compression (Figure 1). A core biopsy confirmed benign thyroid tissue with no evidence of malignancy. Given the worsening dysphagia and respiratory compromise, surgical intervention was deemed necessary.

Figure 1.

(a) Sagittal view of the goiter showing a 15.85 cm component in the retropharyngeal space. (b) Coronal view of the goiter showing a 11.15 cm length. Tracheal compression is depicted. (c) Axial view of the goiter with dimensions of 11.39 × 5.93 cm. The retropharyngeal space is highlighted, and tracheal compression is further depicted.

The patient underwent a total thyroidectomy with complete transcervical removal of the substernal component approximately 7 days after initial hospital admission. Gross pathology of the excised thyroid revealed two unoriented globoid portions of thyroid tissue, with the largest measuring 12.2 × 5.5 × 3.6 cm and a total weight of 343 g (Figure 2). Histopathological examination confirmed thyroid follicular nodular disease; no evidence of malignancy was identified which matches prior core biopsy findings.

Figure 2.

Gross appearance of the resected thyroid gland. The specimen shows extensive diffuse nodularity.

Given the significant airway distortion caused by the retropharyngeal extension of the goiter, meticulous airway management was required preoperatively. Prior to the initiation of the surgery, the patient’s in situ endotracheal tube was exchanged for a Medtronic NIM™ EMG endotracheal tube utilizing a Glidescope^® video-laryngoscope (Verathon Medical, Bothell, WA, USA) to facilitate recurrent laryngeal nerve monitoring. During this procedure, the posterior pharyngeal wall was noted to be anteriorly displaced, and view of the glottis was difficult to obtain. As such, we were prepared to perform fiberoptic intubation if the endotracheal tube could not be successfully placed.

Preoperatively, an esophageal bougie was advanced transorally into the esophagus to allow for identification of the hypopharynx and esophagus by palpation during surgery. This was an important adjunct as the regional anatomy within the retropharyngeal space was significantly altered by the goiter. Meticulous dissection of the retropharyngeal component of the goiter was required as it abutted the pharyngeal constrictor muscles, and this allowed us to successfully avoid injury to the pharyngo-esophagus.

The four parathyroid glands were identified in their normal anatomic positions. The right inferior parathyroid gland was deemed devascularized at the conclusion of the surgery and was autotransplanted into the ipsilateral sternocleidomastoid muscle. The bilateral recurrent laryngeal nerves were identified and preserved with intact response to stimulation following removal of the goiter.

Postoperative course

Immediately following surgery, the patient remained endotracheally intubated due to mild laryngeal edema. Her postoperative parathyroid hormone (PTH) level was within the normal range, and she did not require supplemental calcium. On postoperative day 1, she met criteria for extubation, and the endotracheal tube was removed. Flexible fiberoptic laryngoscopy was performed, and the true vocal folds exhibited full mobility. The patient did have dysphagia postoperatively which necessitated placement of a percutaneous gastrostomy tube for temporary nutritional support. She was discharged to a subacute rehabilitation facility with the percutaneous endoscopic gastrostomy (PEG) tube in place. It remained in place for 1 month during intensive swallow rehabilitation under the guidance of speech-language pathology. After removal, the patient was able to sustain a normal oral diet. Her dysphagia could be attributed to a combination of factors. The prolonged growth of the goiter at least 12 years in the retropharyngeal space may have led to adaptations in swallowing mechanics given the anterior migration of the posterior pharyngeal wall. Removal of the massive retropharyngeal goiter, undoubtedly, caused the posterior wall to migrate posteriorly into its normal location. As such, the laryngopharynx experienced a significant change in its anatomy following surgery. Given the patient’s advanced age, her ability to adapt her swallow in order to overcome this change may have been inhibited. Therefore, intensive dysphagia therapy with speech-language pathologists was necessary to optimize her swallowing function and facilitate safe nutritional intake.

Discussion

Retropharyngeal goiters are exceedingly rare with limited documented cases in the literature. Table 1 provides a summary of these cases and highlights their clinical characteristics, management, and outcomes.^1–10 Despite the rarity of these cases, several commonalities emerge including the predominance of compressive symptoms such as dysphagia, dyspnea, and dysphonia.

While multinodular goiter remains the most common histopathological diagnosis in retropharyngeal goiters, other thyroid pathologies have been reported such as Hashimoto’s thyroiditis.^2,8 Additionally, Khan et al. described a 35-year-old female with a retropharyngeal goiter initially suspected to be a multinodular goiter but was later diagnosed with Riedel’s thyroiditis. ¹¹

Surgical management via total thyroidectomy remains the mainstay of treatment for retropharyngeal goiters to relieve compressive symptoms and prevent further complications. However, these cases present unique intraoperative challenges, particularly in elderly patients who have reduced physiologic reserve, an increased risk of perioperative complications, and a higher likelihood of postoperative dysphagia due to age-related changes in swallowing function. ¹² During surgery, care must be taken to avoid injury to the mucosa of the pharyngo-esophagus and surrounding musculature. Damage to these structures can lead to postoperative complications, including dysphagia, aspiration or salivary leakage. Our surgical team took extra precautions to preserve the integrity of these tissues, given the long-standing compression of the laryngopharynx by the goiter.

In addition, careful airway planning must be performed jointly between the surgical and anesthesiology teams involved given the distortion of the laryngopharynx possible with retropharyngeal goiters. These cases require proactive strategies to ensure airway security and intraoperative visualization. Specifically, providers must be prepared to perform awake fiberoptic intubation or even awake tracheostomy, should it be required. Given our patient’s significant tracheal compression and preexisting intubation, transitioning to an endotracheal tube suitable for recurrent laryngeal nerve monitoring was an essential step in preserving vocal function. Finally, the use of an esophageal bougie or dilator was particularly valuable in maintaining intraoperative orientation within a highly distorted anatomical field, minimizing the risk of esophageal injury.

The mechanism underlying retropharyngeal thyroid extension remains unclear, as no definitive etiologic pathway has been firmly established in the literature. However, among the available proposals, progressive posterior extension of an enlarging goiter through fascial planes appears to be the most consistent with both anatomical pathways and the clinical findings observed in our case.

The anatomy of the cervical fascial compartments does provide a potential route for an enlarging thyroid to reach the retropharyngeal space. The thyroid gland is enveloped by the visceral layer of the deep cervical fascia (pretracheal fascia) and normally confined to the anterior neck. ¹⁰ Superior migration is limited by attachments of the sternothyroid muscles and the confines of the pretracheal fascia. ¹⁰ Consequently, large goiters most often expand inferiorly into the mediastinum (retrosternal goiters) rather than upward. ¹⁰ However, a massive goiter can, in rare cases, dissect posteriorly. The visceral fascia housing the thyroid is continuous with the buccopharyngeal fascia, creating a potential space that extends from the thyroid bed up behind the pharynx (the retrovisceral space, comprising retropharyngeal and retroesophageal spaces).^{4–6,8,10,13} This continuity of fascial planes offers an anatomical explanation for the extension of a goiter into the retropharyngeal space. ¹³ Surgical anatomy reports confirm that an enlarged thyroid lobe can physically extend posteriorly into the parapharyngeal and retropharyngeal spaces while remaining contiguous with the main gland.^5,14.

Radiologic evidence from our case strongly supports this displacement theory, as computed tomography imaging demonstrated direct continuity between the enlarged cervical thyroid and the retropharyngeal extension (Figure 1). This connection reinforces the interpretation that the mass represents posterior tracking of a multinodular goiter rather than an isolated or ectopic lesion. Similarly, the majority of published adult cases (Table 2) also describe large multinodular goiters with superior and posterior tracking into the retropharyngeal space, while maintaining continuity with the thyroid gland in the neck.^3–5,7,9

Table 2.

Past reported cases of retropharyngeal goiter and clinical characteristics.

Authors and years of publication	Age	Gender	Symptom(s) upon presentation	Thyroid size	Hormone levels of thyroid	Management	Histopathology	Associated history
Soboroff et al. (1977) 1	42	F	Loud breathing	Enlarged	Euthyroid	Total thyroidectomy	Not reported	Not reported
Kenyon and Robb (1981) 2	57	M	Voice changes	Normal	Hypothyroid	Biopsy	Hashimoto thyroiditis	Not reported
Som and Shugar (1991) 3	79	F	Dyspnea	Enlarged	Euthyroid	Total thyroidectomy	Multinodular goiter	Not reported
Som and Shugar (1991) 3	71	F	Dyspnea	Enlarged	Euthyroid	Total thyroidectomy	Multinodular goiter	Not reported
Atasoy et al. (2002) 4	78	M	Dysphagia, dysphonia	Enlarged	Euthyroid	Total thyroidectomy	Multinodular colloidal goiter	Iodine-deficient environment
Lakhani et al. (2010) 5	63	M	Dysphagia, dysphonia, dyspnea	Enlarged	Euthyroid	Total thyroidectomy	Nodular colloid goiter	Long history of dysphagia, dysphonia, dyspnea; 1-day history of foreign body sensation
Baik et al. (2017) 6	97	F	Dysphagia, odynophagia, dyspnea	Enlarged	Not reported	Total thyroidectomy	Multinodular goiter	3-year history of progressive symptoms
Baik et al. (2017) 6	51	F	Dyspnea	Enlarged	Not reported	Right lobectomy	Multinodular goiter	5-year history of enlarging goiter
Thomas et al. (2017) 7	53	M	Dysphagia, dyspnea	Enlarged	Not reported	Total thyroidectomy	Multinodular hyperplasia and incidental 0.6 cm papillary microcarcinoma in the left lobe	10-year history of enlarging goiter with increasing symptoms
Alhedaithy et al. (2022) 8	70	M	Asymptomatic	Enlarged	Euthyroid	Total thyroidectomy	Hashimoto thyroiditis	1-year prior neck mass was noticed; Hashimoto thyroiditis
Tola et al. (2023) 9	30	F	Dyspnea, orthopnea	Enlarged	Euthyroid	Total thyroidectomy	Multinodular goiter	15-year duration of noticed neck swelling; Iodine-deficient environment
Alqahtani et al. (2024) 10	62	F	Asymptomatic	Enlarged	Euthyroid	Total thyroidectomy and sternotomy	Follicular nodular disease (multinodular goiter)	1 year noticed before presentation
Alqahtani et al. (2024) 10	49	M	Asymptomatic	Enlarged	Euthyroid	Total thyroidectomy	Multinodular goiter with hyperplasia	3 months noticed before presentation
Our patient (2025)	89	F	Dysphagia, hoarseness of voice	Enlarged	Euthyroid	Total thyroidectomy	Multinodular goiter	12-year history of enlarging goiter and symptoms

In the majority of published cases, histopathology revealed long-standing multinodular goiters (often euthyroid or associated with benign pathologies such as Hashimoto’s or Riedel’s thyroiditis) that exhibit an unusual posterior extension.^1–11 This reinforces that these masses are typically both anatomically and histologically continuous with the cervical thyroid gland.

An alternative embryological explanation would not be feasible because there is no evidence of ectopic thyroid tissue. This would suggest aberrant thyroid descent during embryogenesis, resulting in thyroid tissue in atypical locations, such as the retropharyngeal space. However, to date, the only reported case in the literature of truly ectopic thyroid tissue occupying the retropharyngeal space was described by Dalgiç et al. in a neonate, with no continuity to a normally positioned thyroid gland. ¹⁵ This congenital presentation is markedly different from adult-onset cases, including ours, where imaging and surgical findings consistently show direct continuity between the retropharyngeal extension and the orthotopic thyroid gland. Thus, while the embryologic theory may apply to rare congenital anomalies, it does not align with the clinical, radiologic, or histologic characteristics of adult multinodular goiters with retropharyngeal involvement.

This case provides insights beyond prior literature by detailing the specific intraoperative adaptations required to manage a long-standing, progressively enlarging retropharyngeal multinodular goiter. While airway distortion and surgical risks have been noted in previous reports, specific strategies for optimizing surgical safety have not been well documented. These include preemptive endotracheal tube exchange for nerve monitoring, intraoperative esophageal bougie placement to maintain anatomical orientation, and preoperative consideration of alternative airway management approaches. Additionally, our case highlights the unique postoperative challenges posed by extensive and prolonged laryngopharyngeal compression, particularly regarding the risk of dysphagia in elderly patients. This underscores the importance of a multidisciplinary approach, integrating surgical, anesthetic, and rehabilitative considerations to optimize both procedural safety and functional outcomes.

Conclusion

Retropharyngeal goiters are rare entities. This case report highlights the successful surgical management of a massive retropharyngeal goiter in an 89-year-old female. While the precise mechanism underlying retropharyngeal thyroid displacement remains uncertain, the most plausible explanation is progressive glandular enlargement through fascial planes. We present an approach to the workup and management of these types of goiters with high-yield perioperative considerations for airway management and identification of the esophagus. Finally, the postoperative care of these patients is highlighted, and the importance of multidisciplinary dysphagia management is stressed. Further research is needed to fully elucidate the etiology and pathogenesis of this rare condition, leading to improved diagnostic strategies and tailored treatment approaches.