Despite being common condition, the definition of thyroid goiter remains controversial and defined ambiguously by clinical definition of ‘enlargement of the thyroid gland’, avoiding a clearer quantitative definition by size, volume or weight by leading guidelines [1,2]. Causes for goiter are probably multi-factorial, with a strong genetic and environmental component [3].

In line with disagreement regarding its definition, the management of thyroid goiter remains debated as well. Agreed indications for surgery include symptoms such as dyspnea, dysphagia or severe compression on imaging. Other indications relate to extensive retrosternal growth, suspicious of malignancy and patients' preference. As radiographic findings may not necessarily correlate with clinical complaints, the decision to recommend a surgery should be done after risk and benefits of the procedure are discussed with the patient. Regardless of symptoms, the risk of malignancy (ROM) in thyroid goiters remains an important consideration in their management. Published ROM varies greatly, ranging from 3 %–16.6 % for incidental thyroid malignancy, reaching 46.5 % when including microcarcinoma [4]. Furthermore, the reliability of fine needle aspiration (FNA) for large thyroid nodules has also been debated, with inconsistent results [[5], [6], [7], [8]]. This has led to different conclusions on optimal management for goiters, from mandatory resections for all to a safe clinical follow-up [[9], [10], [11]].

The data suggests that an effort should be made to better stratify patients with goiter, considering the ROM, the potential for developing symptoms and the risk of post-operative complications. Several works have tried to stratify ROM and airway management based on size [12], yet such association was not found. We hypothesized that a goiter size and nodularity may affect both ROM and post-surgical complications. Based on our population, which have a high rate of endemic goiters, we performed an analysis comparing extra-large goiters, defined as 8 cm and above to goiter sized 4–8 cm, hypothesizing that extra-large would carry a higher rate of significant malignancy (>1 cm) and may result in higher surgical complications rate.