- After documentation of thyroid size:
- The examiner should note the:
- Consistency and fixation of the mass:
- Especially with respect to the larynx and trachea
- Consistency and fixation of the mass:
- The examiner should note the:
- 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
- Is clearly an inaccurate method of assessment:
- Estimated weight based on the physical examination:
- Generally underestimates multinodular goiter weight:
- By 25 to 50 g
- Generally underestimates multinodular goiter weight:
- 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
- Deviation from the midline:
- 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
- Although this may be present with large benign cervical or substernal goiter:
- Adenopathy as well as scarring:
- 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
- Presumably through stretch:
- It should be noted, however, that benign goiter has also been associated with vocal cord paralysis:
- Implies invasive thyroid malignancy until proved otherwise:
- Certainly, such a preoperative finding focuses the surgeon’s attention on the extreme importance of preserving the contralateral RLN
- Vocal cord paralysis without a history of past thyroid surgery:
- 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
- Vocal cord paralysis was only found in 3%
- Michel noted in his series of substernal goiters that although hoarseness was described in 26%:
- Roughly 2% of patients with goiter present with vocal cord paralysis in the setting of benign disease and no prior neck surgery:
- 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
- Given the restriction of the bony confines of the thoracic inlet:
- 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
- Although the maximum tracheal deviation with substernal goiter usually occurs at the thoracic inlet:
- 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
- 10% to 30% of substernal goiter patients:
- 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
- Cervical mass is noted in 69% to 97% of the cases:
- 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
- Wax and Briant have noted that, with careful questioning:
- Are symptomatic at presentation:
- 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
- Hematemesis secondary to downhill esophageal varices:
- 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
- Show 70% to 80% of substernal goiter patients:
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