Clinical Presentation of Patients with Goiter

• The clinical manifestations of goiter:
  • Depends upon the presence of thyroid dysfunction and upon the growth rate of the goiter
• Some patients may have symptoms and biochemical evidence of hypothyroidism or hyperthyroidism:
  • However, the majority of patients with goiter:
    • Are asymptomatic and biochemically euthyroid
• Patients with longstanding, large goiters:
  • May develop symptoms of obstruction:
    • Due to progressive compression of the trachea or sudden enlargement (usually accompanied by pain):
      • Secondary to hemorrhage into a nodule
• Asymptomatic:
  • Most goiters grow very slowly over many decades:
    • Therefore, the majority of patients with goiter:
      • Are asymptomatic
• The goiter may first be noted on:
  • Physical examination or
  • Found incidentally on cross-sectional imaging studies performed for unrelated reasons
• Thyroid dysfunction:
  • If the goiter is due to Hashimoto’s thyroiditis or severe iodine deficiency:
    • Patients may have symptoms of hypothyroidism:
      • For example:
        • Fatigue, constipation, cold intolerance
  • If due to multinodular goiter (with autonomy) or Graves’ disease:
    • Patients may have symptoms of hyperthyroidism:
      • For example:
        • Palpitations, dyspnea on exertion, unexplained weight loss
• Obstructive symptoms:
  • Patients with longstanding goiters (cervical or substernal) may develop symptoms of obstruction:
    • Due to progressive compression of the trachea or sudden enlargement (usually accompanied by pain):
      • Secondary to hemorrhage into a nodule
  • The majority of patients with obstructive cervical goiters:
    • Have had a visible goiter for many years
• Most patients with substernal goiter (77% to 90% in two series) also have visible goiters:
  • Although some are found incidentally on imaging studies performed for unrelated reasons
• In those without visible goiter:
  • Substernal goiters may also be found:
    • Because of obstructive symptoms
• Since goiters tend to grow slowly:
  • Substernal goiters are most commonly discovered:
    • During the fifth and sixth decades of life:
      • And are found more often in women than men
• The most common symptom in patients with obstructive cervical or substernal goiter:
  • Is exertional dyspnea:
    • Which is present in 30% to 60% of patients:
      • This symptom usually occurs when:
        • The tracheal diameter is less than 8 mm
• In some patients with substernal goiter:
  • Dyspnea is primarily positional or nocturnal:
    • And it occurs primarily during maneuvers that force the thyroid into the thoracic inlet:
      • Such as reaching and bending
• When tracheal compression becomes severe (luminal diameter less than 5 mm):
  • Stridor or wheezing occurs at rest:
    • This upper airway wheezing must be distinguished from asthma
• An upper respiratory illness:
  • May exacerbate upper airway obstruction
• Cough:
  • Is present in 10% to 30% of patients:
    • And it may be positional
• Pain is unusual
• Choking sensation is common
• Goiter may contribute to obstructive sleep apnea:
  • And thyroidectomy may improve symptoms:
    • In a study of 45 patients with snoring symptoms who were undergoing thyroidectomy for any reason (42% for goiter or compressive symptoms):
      • 29% had improved snoring frequency, apnea, and frequency of daytime somnolence after surgery
• A variety of other symptoms can be induced by obstructive goiter:
  • Dysphagia:
    • Is a less common complaint because of the posterior position of the esophagus
• Compression of a recurrent laryngeal nerve:
  • May cause transient or permanent vocal cord palsy:
    • Resulting in hoarseness
• Phrenic nerve paralysis
• Horner’s syndrome:
  • Due to compression of the cervical sympathetic chain
• Rarely:
  • Jugular vein compression or thrombosis
  • Cerebrovascular steal syndromes
  • Even the superior vena cava syndrome

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