Substernal goiter is a form of thyroid enlargement that can compress mediastinal structures, including the trachea, leading to respiratory symptoms. We present the case of a 65-year-old female patient with a large, nontoxic substernal goiter who developed acute respiratory failure. Due to rapidly progressing dyspnea, an emergency tracheotomy was performed, and because of difficulties in achieving adequate ventilation, a decision was made to perform a simultaneous total thyroidectomy. Postoperative complications included right-sided pneumothorax, which required chest drainage. After stabilization of respiratory function and general condition, the patient was transferred to the surgical ward and subsequently discharged home with recommendations for levothyroxine substitution and further endocrine and otolaryngologic follow-up. This case highlights the importance of prompt diagnosis and surgical intervention in goiter-induced acute airway obstruction, as well as the need for vigilant monitoring of postoperative complications such as pneumothorax.