66 AJTCCM VOL. 31 NO. 2 2025
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Background. ‘Forgotten’ goitre (FG) is a mediastinal portion of the thyroid found aer total thyroidectomy. It is extremely rare.
Objectives. To report on 5 cases and review the literature.
Methods. We retrospectively reviewed all patients with retrosternal goitre at Mohammed V Military Teaching Hospital, Rabat, Morocco,
from 1 January 2010 to 31 December 2020 and identied 5 patients who underwent surgery for forgotten mediastinal goitre during this
period. Data on patient characteristics, time of the rst thyroidectomy, imaging (chest radiograph, chest computed tomography (CT) scan
and magnetic resonance imaging), surgical approach, pathological ndings and postoperative complications were collected.
Results. Five patients (3 female and 2 male) with a mean age of 46.2years (range 32-56years) with FG had surgery. Two patients were
asymptomatic and 3 patients had dyspnoea, 2 of whom also had dysphonia and 1 signs of hyperparathyroidism. No patient had a history of
thyroid cancer. e average time between the rst thyroidectomy and re-operation was 4.3years. e diameter of the masses on CT scan was
7-12cm. All the patients underwent sternotomy. Postoperative transitory le recurrent laryngeal nerve palsy occurred in 1 case. ere were
no postoperative deaths. Pathological examination of the mediastinal goitre conrmed multi-heteronodular thyroid hyperplasia in all cases.
Conclusion. FG is an extremely rare condition, which can be prevented with thorough preoperative imaging.
Keywords. Forgotten goitre, mediastinum, chest computed tomography, recurrent nerve palsy, sternotomy.
Afr J Thoracic Crit Care Med 2025;31(2):e762. https://doi.org/10.7196/AJTCCM.2025.v31i2.762
‘Forgotten’ goitre (FG) is a mediastinal thyroid mass found aer total
thyroidectomy for retrosternal goitre. e frequency reported in the
literature varies between 2% and 16% of cases of retrosternal
goitre.[1-5] A search using the terms ‘forgotten goiter aer thyroidectomy’
and ‘missed goiter aer thyroidectomy’ in the PubMed and Google
Scholar databases showed that ~40 cases have been reported. Neck and
chest computed tomography (CT) and/or chest magnetic resonance
imaging (MRI) play an important role in the preoperative work-up of
patients with FG to prevent complications. Preopera tive imaging is also
important before initial thyroidectomy to avoid missing thyroid tissue.
Methods
Between 1 January 2010 and 31 December 2020, 4 266 patients
underwent thyroid surgery at Mohammed V Military Teaching
Hospital, Rabat, Morocco. Of these, 167 (3.9%) had retrosternal
goitre and were operated on by the thoracic surgery department. In
the majority of these cases (n=161; 96.4%) a cervical approach was
possible, while 6 patients (3.6%) required a sternotomy. Five cases
of FG were identied. All these patients were referred from other
departments or hospitals. Data on age, gender, symptoms, initial
pathological ndings, hormone tests (free tri-iodothyronine, free
thyroxine, thyroid-stimulating hormone (TSH)), radiological ndings
(chest radiograph, CT, MRI), surgical approaches, postoperative
complications and hospital stay were collected from medical records.
Laryngoscopy was routinely performed to assess recurrent laryngeal
nerve function.
Results
e patients ranged in age from 32 to 56years (mean 46.2), and 3 of
them were female. e time between the thyroidectomy and discovery
of the mediastinal mass ranged from 6months to 8years, with an
average of 4.3years (Table1).
Symptoms were present in 3 patients, all of whom had dyspnoea
secondary to tracheal compression, with dysphonia in 2 cases and
signs of hyperparathyroidism in 1 case. In 2 cases the diagnosis was
made through systematic radiological examination. Chest radiographs
and neck and chest CT scans were done in all cases, and chest MRI
was performed in 2 cases.
‘Forgotten’ goitre aer total thyroidectomy
E H Kabiri,1,2 MD, PhD ; M El Hammoumi,1 ; M Bhairis,1 MD ; M Kabiri,2 MD, PhD
1 Department of oracic Surgery, Mohammed V Military Teaching Hospital, Rabat, Morocco
2 Faculty of Medicine and Pharmacy, University Mohammed V Rabat, Morocco
Corresponding author: E H Kabiri (hassankabiri@yahoo.com)
Study synopsis
What the study adds. ‘Forgotten’ goitre is a mediastinal portion of the thyroid found aer total thyroidectomy. It is extremely rare.
Wereport on 5 cases.
Implications of the ndings. orough preoperative imaging of retrosternal goitre can prevent the occurrence of forgotten goitre and
its associated morbidities. Sternotomy is usually required for reoperation, highlighting the importance of complete initial thyroidectomy
.
AJTCCM VOL. 31 NO. 2 2025 67
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Standard chest radiographs (Fig.1A) revealed
a mass in the upper mediastinum with tracheal
deviation or compression, and tracheal
stenosis in 1 case.
e goitre extension was on the le side in 4
cases (Fig.1A) and on the right side in 1 case.
Neck and chest CT scans (Fig.1B and C)
showed the masses to be situated in the upper
mediastinum. e average size of the goitres
was 9.7 cm x 6.4 cm x 5 cm.
Two patients had both CT and MRI scans
(Fig.2). On T1-weighted imaging the masses
were hypo-intense and on T2-weighted
imaging they were hyper-intense. Injection of
gadolinium enhanced image quality.
yroid hormone levels were normal in 4
cases. One patient had hyperthyroidism.
All the patients were operated on via
sternotomy (total in 2 cases and partial in 3
cases) (Fig.3).
e ndings on postoperative laryngoscopy
were normal in 4 cases. One patient had a
slight decrease in mobility of the left vocal
cord. is transitory le recurrent nerve palsy
was treated with phonatory rehabilitation
sessions. The hospital stay was 5-10 days
(mean 6.6days).
In all cases, pathological examination of the
goitre revealed multi-heteronodular thyroid
Table1. Characteristics of patients with ‘forgotten’ goitre
Characteristic Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Sex, age (years) F, 32 M, 56 F, 49 F, 44 M, 50
Time since rst
thyroidectomy
8years 6years 6months 3years 4years
Histological ndings
(rst thyroidectomy)
Benign multinodular
goitre
Benign multinodular
goitre
Benign multinodular
goitre
Benign multinodular
goitre
Benign multinodular
goitre
Symptoms Dyspnoea,
dysphonia, signs of
hyperthyroidism
Incidental Dyspnoea Dyspnoea,
dysphonia, chest
pain
Incidental
Radiological ndings
Chest radiograph Le tracheal
deviation
Right tracheal
deviation
Right tracheal
deviation
Right tracheal
deviation
Right tracheal
deviation
Neck/chest CT scan Right, 12 cm x
6.5 cm x 5.5 cm
Le, 8 cm x
5 cm x 4 cm
Le, 11 cm x
6.5 cm x 5.5 cm
Le, 10.6 cm x
7.6 cm x 5 cm
Le, 7 cm x
6.3 cm x 5.2 cm
Chest MRI Not done Not done Not done 9.8 cm x 9.3 cm x
6.7 cm
6.7 cm x 6 cm x
5 cm
Hormonal ndings Hyperthyroidism Euthyroidism Euthyroidism Euthyroidism Euthyroidism
Surgical approach Partial median
sternotomy
Total median
sternotomy
Partial median
sternotomy
Total median
sternotomy
Partial median
sternotomy
Postoperative
complications
Transitory le
recurrent nerve
paralysis
None None None None
Histological ndings Benign multinodular
goitre
Benign multinodular
goitre
Benign multinodular
goitre
Benign multinodular
goitre
Benign multinodular
goitre
Hospital stay (days) 10 5 6 7 5
F = female; M = male; CT = computed tomography; MRI = magnetic resonance imaging.
A C
B
Fig.1. (A) Chest radiograph showing a large well-dened opacity in the le hilar region. (B and
C) Chest computed tomography scan showing a well-dened, slightly rounded mass of thyroid
tissue that descends into the mediastinum down to the hilum.
68 AJTCCM VOL. 31 NO. 2 2025
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hyperplasia without signs of malignancy. All
the patients recovered uneventfully.
Discussion
‘Forgotten’ goitre or ‘missed thyroid gland’
is an extremely rare condition, defined as
the presence of thyroid issue as a mass in
the medias tinum aer total thyroidectomy.
[2] In the majority of cases, the ‘forgotten’
gland is the result of incomplete resection of
plunging cervical goitre, but sometimes it is
due to existence of intrathoracic autonomous
ectopic goitre without parenchymal or
vascular connections to the thyroid.[2,3,6] e
appellation ‘forgotten’ was used in 1992 by
Massard et al.,[2] referring to ‘mediastinal
masses of thyroid tissue diagnosed after
subtotal thyroidectomy for substernal goiter
that do not have visible connection to the
cervical thyroid gland’.
Two situations are possible: either the
retrosternal portion of the thyroid is
connected to a cervical portion that was
forgotten during total thyroidectomy (or
not resected), or occasionally there is an
autonomous goitre (estimated incidence
0.19%) located in the mediastinum without
connections (parenchymatous or vascular) to
the cervical part of the thyroid gland.[2,7,8] An
autonomous goitre is related to an abnormal
embryonic progression of the thyroid
gland. The ectopic thyroid tissue therefore
results from the abnormal embryological
migration of thyroid tissue, the anatomical
communications between the neck and the
chest (mediastinum), and the presence of
pyramidal lobe, thyrothymic and Zuckerkandl
remnants.[9]
e incidence of FG is between 2% and 16%
of retrosternal goitres in large series,[3] and its
occurrence has usually been due to oversight
rather than the autonomous ectopic forms.
Our PubMed and Google Scholar literature
search discovered ~40 cases (Table 2).
According to Sackett etal.’s [10] classication,
remaining thyroid tissue can be missed aer
total thyroidectomy owing to impermanence
of the link between thyroid tissue and the
remnants in 20% of cases. Close attention must
therefore be paid to preopera tive imaging and
intraoperative management during the rst
operation[9] to avoid missing thyroid tissue.
The symptoms of FG are compression
of mediastinal structures or signs of
hyperthyroidism, so it should be strongly
suspected when postoperative thyroid
hormone (TSH) levels remain unchanged.
Sometimes, however, the mediastinal mass
is discovered incidentally in asymptomatic
patients,[1,3] e latent period between the
first thyroidectomy and discovery of the
FG is variable: 1 day in the Ismail etal.[11]
report, 2-39years in Massard etal.,[2] and
1month-25years in Courvoisier etal.[12]
In our case series the average period was
4.3years.
Preoperative neck and chest CT scanning is
essential to identify the exact size and location
of the mass and any adhesions to mediastinal
vessels, the trachea and the oesophagus. e
CT scan also enables investigation of the
characteristics of the mediastinal thyroid
mass such as regular contour, presence of
calcications in the mass, high density and
intense intake of contrast medium,[1-3] and
planning of the surgical approach to minimise
operative complications. Coronal and sagittal
planes in the chest MRI scan enable precise
identification of all the adjacent organs,
particularly the great vessels.[1,3] Thyroid
scintigraphy is useful in patients with a
past history of thyroid resection. However,
sometimes thyroid scintigraphy is negative
because the thyroid tissue is positioned deep
in the mediastinum or there is low absorption
of the tracer photons by the sternum and
other surrounding tissues.[2,3]
Surgery is the best treatment for FG
when possible. It confirms the diagnosis
and relieves mediastinal compression. The
choice of approach (cervicotomy, sternotomy,
thoracotomy or a combined approach) is
determined by the exact topography of the
mass and its relationship with the mediastinal
structures.[1-3,13] e simple approach via repeat
cervicotomy is probably preferable when
A B
Fig.3. Operative views. (A) Resection of a mediastinal forgotten goitre
through a sternotomy. (B) e resected missed goitre.
A B
C
Fig.2. Axial (A, B) and coronal (C) magnetic resonance imaging showing a mediastinal lesion
with high T2 signal intensity.
AJTCCM VOL. 31 NO. 2 2025 69
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Table2. Summary of cases of ‘forgotten’ goitre in the literature
Reference Cases, N
Sex, age
(years), range
(mean)* Symptoms
Time since rst
thyroidectomy,
range (mean)*
Histological
ndings, rst
thyroidectomy
Surgical
approach
Histological
ndings of the
‘forgotten’ mass
Calò etal.,[1]
2012
7 6 F, 1 M,
25-70 (56)
4 asymptomatic
2 mediastinal
compression
1 persistent
hyperthyroidism
- NR 4 cervicotomy
3 partial
sternotomy
No neoplasia
Massard
etal.,[2]
1992
7 5 F, 2 M,
47-67 (56)
4 mediastinal
compression
1 hypertyroidism
2 asymptomatic
2-39years
(16.1years)
No neoplasia 1 cervicotomy
3 sternotomy
3 cervico-
sternotomy
No neoplasia
Lucchini
etal.,[4]
2014
4 3 F, 1 M,
46-56
4 asymptomatic Mean 10years 1 thyroid cancer
metastasis in
laterocervical
nodes
3 nodular
hyperplasia
1 cervicotomy
2 cervico-
sternotomy
1 cervico-
sternotomy
and right
posterolateral
thoracotomy
1 follicular
carcinoma
3 nodular
hyperplasia
Sahbaz etal.,[6]
2013
2 F, 37
M, 72
2 persistent
hyperthyroidism
4weeks-7years 1 papillary
cancer
1 Graves’
disease
1 mini-
sternotomy
1 sternotomy
1 papillary
cancer
1 papillary
carcinoma
Patel etal.,[8]
2016
1 F, 54 Incidental chest
X-ray for routine
surgery aer
5years
5years Hashimoto’s
thyroiditis
Trans-cervical Nodular
hyperplasia
Faroq etal.,[9]
2018
1 F, 58 Persistent
hypertyroidism
~2years
(23months)
Micropapillary
carcinoma
Cervicotomy Follicular lesion
Ismail etal.,[11]
2019
1 F, 57 Incidental
imaging for
other health
condition
1 day Multinodular
goitre without
malignancy
Cervicotomy Multinodular
goitre without
malignancy
Courvoisier
etal.,[12]
2015
11 8 F, 3 M,
34-71 (56.6)
NR 1month-25years
(10.6years)
NR 4 cervicotomy
1 cervico-
sternotomy
4 thoracotomy
(only 9
operated on)
2 invasive
thyroid cancer
7 benign goitre
Grigoletto
etal.,[14]
1997
1 F, 59 Respiratory
distress + cough
7years No neoplasia Cervicotomy No neoplasia
Khan etal.,[15]
2016
1 F, 59 Dyspnoea
+ stridor
25years aer
thyroidectomy
25years Benign
multinodular
goitre
Partial median
sternotomy
Benign
multinodular
goitre
Lee etal.,[16]
2005
1 F, 27 Incidental
imaging for
other health
condition
35months Adenomatous
hyperplasia
Sternotomy Adenomatous
hyperplasia
Casadei
etal.,[17]
2002
1 M, 59 Mediastinal
compression
3months Nodular
hyperplasia with
7 mm follicular
microcarcinoma
Sternotomy Nodular
hyperplasia
(continued
70 AJTCCM VOL. 31 NO. 2 2025
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possible, because it is less traumatic with simple postoperative care, a
short hospital stay, and a quick return to normal life and physical and
professional activity.[1,4,8,9,13,14] However, brotic cleavage planes aer
the rst thyroidectomy, and deep mediastinal adhesions aer a long
delay (>2years is usually considered a long delay in this context), make
surgical resection unsafe and dicult.[1,3,4] In this situation, sternotomy
is the preferred procedure in view of the serious risk of mediastinal
vascular injury and the possibility of a fatal outcome.[2,3,6,15-18] This
method is straightforward and safe, with good cosmetic results and a
low rate of postoperative complications, similar to that of cervicotomy.
A right posterolateral thoracotomy is indicated in specic cases
(right lateralised masses) according to the ndings on preoperative
imaging,[3,4,12] oering good exposure and full control of the right
mediastinum. Courvoisier et al.[12] undertook resection of FG in
4cases using the thoracotomy approach alone, but in one of the cases
reported by Lucchini etal.,[4] this approach was used to complement
cervico-sternotomy.
Common complications of thyroid surgery were not reported in the
literature reviewed, apart from a high rate of recurrent nerve palsy.
Courvoisier etal.[12] reported a high rate of nerve complications of
44% (4 cases of nerve palsy in 9 patients operated on). is high risk
of recurrent nerve injury may be explained by repeat surgery, cervical
brosis, and digital methods of extraction through a cervicotomy.
e use of intraoperative recurrent laryngeal nerve monitoring and
new haemostatic devices for dissection has signicantly reduced the
risk of recurrent nerve damage.[3,4,19] e parathyroid glands are rarely
exposed to surgical trauma, especially in the absence of a cervical
approach.
Paczkowska etal.[20] reported a case of FG in an 88-year-old woman,
who was treated with radioactive iodine (20 mCi I-131) because of
her age. A second dose of 20 mCi I-131 was necessary 1year later.
Aer 15months the patient remained euthyroid and the goitre had
decreased in volume.
Conclusion
FG is a rare condition. It should be considered in patients with previous
thyroid surgery in the appropriate clinical context. It is possible to
prevent FG by preoperative scanning and appropriate postoperative
thyroid disease management. e best treatment for FG is still surgery.
Data availability. e datasets generated and analysed during the present
study are available from the corresponding author (EHK) on reasonable
request.
Declaration. None.
Acknowledgements. None.
Author contributions. EHK: conceived the study design, performed the
operations, and reviewed the manuscript. MEH: collected data and draed
the manuscript. MB: collected data and analysed clinical information. MK:
provided academic supervision and critically revised the manuscript.
Funding.None.
Conicts of interest.None.
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experience and a review of the literature. Ann Ital Chir 2012;83(6):487-490.
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1801-3-503
Table2. (continued) Summary of cases of ‘forgotten’ goitre in the literature
Reference Cases, N
Sex, age
(years), range
(mean)* Symptoms
Time since rst
thyroidectomy,
range (mean)*
Histological
ndings, rst
thyroidectomy
Surgical
approach
Histological
ndings of the
‘forgotten’ mass
Kesici etal.,[18]
2015
1 F, 49 Incidental aer
scintigraphy
NR Papillary
carcinoma
Partial median
sternotomy
Nodular
hyperplasia
and chronic
thyroiditis
Tsakiridis
etal.,[19]
2016
1 M, 63 Dyspnoea +
dysphagia
2years Multinodular
goitre without
malignancy
Cervico-
sternotomy
Multinodular
goitre without
malignancy
Paczkowska
etal.,[20]
2020
1 F, 88 Subclinical
hyperthyroidism
16years Multinodular
goitre
Radioactive
iodine (20
mCi I-131) x
2 doses
No surgery
Kabiri etal.,
2021
(present
study)
5 3 F, 2 M,
32-56 (46.2)
3 dyspnoea
2 incidental
imaging for
other health
condition
6months-8years
(4.3years)
5 benign
multinodular
goitre
Median
sternotomy
3 partial
2 total
5 benign
multinodular
goitre
F = female; M = male; NR = not reported.
*Where applicable.
AJTCCM VOL. 31 NO. 2 2025 71
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Submitted 13 February 2023. Accepted 11 September 2024. Published 2 June 2025.
