Aim: While the need for thyroidectomy in symptomatic retrosternal goiters (RSG) is indisputable, the management of asymptomatic image-detected RSG remains controversial. We compared outcomes and complications of performing thyroidectomy for patients with symptomatic and asymptomatic RSG to create a management algorithm. Materials and methods: Data of patients with RSG between 2011 and 2019 was collected from our prospective electronic thyroid surgery database. Patient comorbidities, risk stratification, symptoms and signs, modality of diagnosis, surgery details, complications, and outcomes were compared between the symptomatic and asymptomatic groups. Results: A total of 42 out of 477 thyroidectomies (8.8%) had RSG based on our definition, with 26 patients (62%) being truly asymptomatic. Detection of RSG was mainly on imaging (88%), with physical examination accurate in only five patients (12%). Six patients (14%) with image-detected incidental RSG on closer questioning had neck tightness and dysphagia that resolved after thyroidectomy. The surgery involved 23 total thyroidectomies and 19 hemithyroidectomies, with no statistically significant differences between the two groups in terms of operative time, nerve injury, hypocalcemia, or blood loss. The overall incidence of malignancy was 9.5%. Cervical thyroidectomy was successful in all asymptomatic patients, whereas two patients in the symptomatic arm needed an additional extracervical approach. Conclusion: Early thyroidectomy can be safely performed in surgically fit asymptomatic RSG patients with excellent outcomes. Clinical Significance: This paper highlights the issue of asymptomatic RSG, the management of which is controversial. A management algorithm is provided to facilitate a treatment plan and shows that excellent surgical outcomes can be achieved with early thyroidectomy.