Cervical Goiter – History

• The history of goitrous growth and associated symptoms is critical for determining surgical candidacy:
  • This history should be obtained not only from the patient but also from his or her family
• Regional symptoms should be addressed relating to:
  • Respiration
  • Phonation
  • Swallowing
  • Presence of globus (lump sensation)
• As Pemberton emphasized in 1921:
  • Symptoms associated with goiter may be positionally induced
  • Positions that may provoke goiter regional symptomatology include being:
    • Supine
    • Arms raised (as when reaching for an upper cabinet),
    • Extreme neck extension
    • Extreme neck flexion (as with reading a book in bed)
    • Turning the head to the extreme left or right
      • Patients thus need to be questioned about positional provocation of regional symptoms
• In addition, the family needs to be questioned about nocturnal symptoms:
  • As symptoms may manifest initially in the setting of recumbency and upper airway relaxation during sleep
• Symptoms may also be associated with exercise and increased oxygen demands
• A history of preceding upper respiratory tract infection may produce dyspnea in a patient with long-standing tracheal obstruction secondary to goiter:
  • Through new laryngotracheal mucosal edema
• Patients with cervical or substernal goiter may present with:
  • Cough
  • Dyspnea
  • Foreign-body sensation
  • Neck tightness
  • Change in collar size
  • Wheezing:
    • Some patients may come to the head and neck surgeon with a misdiagnosis of asthma or chronic obstructive pulmonary disease (COPD)
• Patients with large cervical and substernal goiter:
  • Approximately 25% of patients were asymptomatic
• Symptoms of hypothyroidism and hyperthyroidism should be reviewed:
  • Hyperthyroidism may slowly evolve in patients with multinodular goiter or may develop acutely in response to significant iodine load such as with CT scan contrast (Jod-Basedow phenomenon) or with the introduction of iodized salt in endemic goiter regions
• A history of migration from an area of endemic goiter should be obtained, as well as a history of exposure to known goitrogens, notably iodine and lithium
• A family history of thyroid disease should be obtained

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