Retrosternal Goiter

Fig. 20.1

Pemberton’s sign. The presence of a retrosternal goiter causes facial flushing and distended superficial veins. Mild flushing is noted with the arms by the side indicating some baseline obstruction at rest

Thyroid cork (deviation of the trachea to the same side as a cervical goiter, due to contralateral retrosternal thyroid enlargement)

Berry’s sign (inability to feel the carotid pulse when the vessels are displaced laterally by the goiter suggests malignancy) (Fig. 20.2)

Fig. 20.2

Coronal MRI scan of a patient with retrosternal goiter. This patient had palpable, laterally displaced neck vessels suggesting benign disease (Berry’s sign), thyroid cork sign (tracheal deviation to the side of the cervical thyroid swelling (left) indicating a hidden (right) retrosternal goiter), and incidental dextrocardia

Investigations

As for thyroid disease confined to the neck, patients should have:

Blood tests: TSH, free T4 and T3, thyroid antibodies, and calcium
FNAC if possible (this may be facilitated by ultrasound)

Prior to surgery more detailed imaging and functional studies may be needed to determine the extent of retrosternal extension and the relation of the thyroid to the structures in the mediastinum:

Magnetic resonance imaging
Computed tomography (with or without contrast)
Respiratory flow loop testing (in patients with compressive symptoms, this may help to predict postoperative tracheomalacia)

The goiter may be recurrent and it is important to check that the patient does not have a vocal cord palsy.

Medical Management

Should the patient be hyperthyroid, liaison with an endocrinologist is essential, and indeed, this may have been the referral source.
Treatment with thionamides may help to render the patient euthyroid and beta-blockers may aid with symptom control.
Radioiodine treatment can be useful to reduce the size of the goiter which may serve to improve compressive symptoms and make any future surgery less difficult in the infirm.