© 2015 Elsevier Inc. All rights reserved. Background Sternotomy for substernal goiters (SSG) is associated with greater morbidity than a cervical approach to thyroidectomy. We sought to identify predictors for sternotomy as a surgical approach for the removal of SSG and analyzed the preoperative and postoperative characteristics of patients with SSG compared with those with large goiters contained entirely within the neck or a cervical goiter. Methods A retrospective review of a surgical database was performed. We included patients with large (>100 g) thyroids or SSG, regardless of size. Between 1995 and 2013, 220 patients met these criteria. Comparisons were made between patients who had an SSG and patients who had a cervical goiter with particular focus on those who required sternotomy. Results Of the 220 patients, 127 patients (58%) had SSG, of whom 7 (5.5%) required sternotomy. All patients who underwent sternotomy underwent preoperative computed tomography scanning and were more likely to have preoperative symptoms of chest pressure and voice complaints and have extension of the thyroid gland below the aortic arch. Sternotomy took an average of 2 hours longer than a cervical incision, was associated with significantly more blood loss (600 versus 190 mL, P = 0.04), and a longer length of stay (3.1 versus 1.8 d, P = 0.03) than cervical thyroidectomy. Conclusions Sternotomy for SSG is rare. All patients necessitating sternotomy had extension below the aortic arch and were more likely to present complaining of chest pressure and voice issues.