Physical Examination in a Patient with Multinodular Goiter

• After documentation of thyroid size:
  • The examiner should note the:
    • Consistency and fixation of the mass:
      • Especially with respect to the larynx and trachea
• Estimation of goiter size by physical examination:
  • Is clearly an inaccurate method of assessment:
    • Jarlov et al. found substantial errors in the clinical assessment of thyroid size as compared with ultrasonographic assessment
• Estimated weight based on the physical examination:
  • Generally underestimates multinodular goiter weight:
    • By 25 to 50 g
• The larynx (landmarks include thyroid notch and anterior cricoid arch) and trachea should be examined for:
  • Deviation from the midline:
    • Typically, cervical goiter will deviate the larynx and trachea to the contralateral side
• The neck must be examined for:
  • Adenopathy as well as scarring:
    • From past thyroid and other neck surgery
  • Jugular distention and subcutaneous venous redistribution should be noted:
    • Although this may be present with large benign cervical or substernal goiter:
      • True superior vena cava syndrome is generally due to malignant thyroid disease and warrants careful scanning and evaluation
• It is imperative in all patients with goiter that the larynx be examined:
  • Roughly 2% of patients with goiter present with vocal cord paralysis in the setting of benign disease and no prior neck surgery:
    • Vocal cord paralysis without a history of past thyroid surgery:
      • Implies invasive thyroid malignancy until proved otherwise:
        • It should be noted, however, that benign goiter has also been associated with vocal cord paralysis:
          • Presumably through stretch:
            • Which may recover postoperatively
    • Certainly, such a preoperative finding focuses the surgeon’s attention on the extreme importance of preserving the contralateral RLN
  • The laryngeal examination in patients with large cervical goiter:
    • Can be difficult if there is edematous or redundant supraglottic mucosa, laryngeal compression and deviation, and hypopharyngeal crowding resulting from goitrous extrinsic compression
  • Symptomatic assessment of the voice, like symptomatic assessment of the airway, does not predict objective findings in patients with goiter and should not replace the laryngeal exam:
    • Michel noted in his series of substernal goiters that although hoarseness was described in 26%:
      • Vocal cord paralysis was only found in 3%
        • I recommend that all patients with goiter undergo preoperative laryngeal examination
• Substernal Goiter
  • In many ways the history and physical examination for patients with substernal goiter overlaps significantly with those for patients with cervical goiter
  • As cervical goiter progresses substernally:
    • Given the restriction of the bony confines of the thoracic inlet:
      • It increasingly compromises the airway
  • In short, substernal goiter evolution is strongly correlated with tracheal deviation:
    • The development of regional airway symptoms, and radiographic airway compression
  • Buckley and Stark noted that:
    • Although the maximum tracheal deviation with substernal goiter usually occurs at the thoracic inlet:
      • It may occasionally occur farther inferiorly
  • Larger surgical series of substernal goiter:
    • Show 70% to 80% of substernal goiter patients:
      • Are symptomatic at presentation:
        • Cervical mass is noted in 69% to 97% of the cases:
          • 10% to 30% of substernal goiter patients:
            • Have no significant palpable cervical abnormality
        • Respiratory symptoms in 42% to 96% of the cases
        • Dysphagia in 26% to 60% of the cases
        • Acute airway presentation in 1% to 5%
        • 3% to 7% present with vocal cord paralysis
      • 4% to 50% are asymptomatic at presentation:
        • Wax and Briant have noted that, with careful questioning:
          • Up to one third of patients who are “asymptomatic” admit to symptoms
    • Pemberton’s sign is described as the development of head and neck venous engorgement with facial congestion, plethora, and venous distention with arms raised over the head:
      • It is sometimes expanded to include the development of transient respiratory insufficiency
      • Pemberton’s sign is thought to indicate goiter extension into the thoracic inlet, with secondary relative venous and airway obstruction
        • Only 4.4% of patients with substernal goiter present with a positive Pemberton’s sign
    • Substernal goiters can also present with:
      • Neck and upper chest pain 
      • Rarely has been associated with:
        • Hematemesis secondary to downhill esophageal varices:
          • Without signs of portal hypertension
        • Abscess formation
        • Horner’s syndrome
        • Chylothorax:
          • Secondary to thoracic duct obstruction
        • Transient ischemic attacks:
          • Through “thyroid steal syndrome”
        • Venous thrombosis
        • Intubation injuries:
          • Especially to the posterior tracheal membranous wall
      • Laryngeal shift to the side of a dominant cervical goiter:
        • Suggests contralateral substernal goiter and requires axial imaging of the neck and chest
      • Similarly, laryngeal shift without any palpable cervical findings suggests substernal goiter and similarly requires axial neck and chest imaging
      • Finally, substernal goiter is suspected when the clavicle intervenes before the inferior extent of the thyroid mass can be palpated

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