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

#Arrangoiz #ThyriodSurgeon #ThyroidExpert #HeadandNeckSurgeon #CancerSurgeon #ThyroidDisease #ThyroidCancer #MultinodularGoiter #Goiter #SubsternalGoiter #CASO #CenterforAdvancedSurgicalOncology

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