Approximately 5% of goitres extend below the thoracic inlet and can potentially become life threatening due to compression of the airway and major vessels. Approximately 7% of these goitres which require surgical resection will need an additional sternotomy to deliver the intra-thoracic component. Massive retrosternal toxic goitres presenting acutely are rare and are described infrequently in literature. We hereby present two cases of massive retrosternal thyrotoxic goitres presenting with acute respiratory failure, requiring non-invasive ventilation, as well as significant head and neck venous compression. Surgery on the thyrotoxic patient with a goitre, even if not significantly enlarged, is associated with a high peri-operative mortality due to cardiac instability and hemorrhage. We discuss the challenges of surgical intervention in these patients with particular emphasis on the timing of surgery to relieve compressive symptoms and the time needed to achieve a euthyroid state. We also emphasize the need for meticulous hemostasis, use of a cell-saver, transfusion protocols, adjuncts to hemostasis, as well as careful monitoring and continuous adjustments to the coagulation profile.
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