Because of the risks of compression of adjacent organs, including the trachea, esophagus, and superior vena cava, resection of an intrathoracic goiter is nearly always indicated even in asymptomatic patients except in the presence of compelling contraindications. In addition, with large retrosternal goiters, FNA biopsy is frequently not applicable, and establishment of the diagnosis may be an important indication for surgery. Most intrathoracic goiters are located anteriorly in front of the subclavian and innominate vessels, but posterior mediastinal goiters with a retrotracheal component constitute 10% to 15% of all intrathoracic goiters. In experienced hands, more than 95% of retrosternal goiters can be resected with a standard collar incision. After the RLN is identified and dissected away from the goiter, either careful finger dissection or the use of a long-handled spoon in a strictly capsular plane allows for safe goiter delivery. Indications for sternotomy include recurrent intrathoracic goiter, a low-lying carcinoma with lymph node involvement, and any unsuccessful cervical delivery of a large goiter. In these cases, an upper midline sternotomy is done in addition to the collar incision.