Substernal Goiter (Retrosternal Goiter) Clinical Presentation

Updated: Dec 10, 2020
  • Author: Steven K Dankle, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Presentation

History

Substernal goiters may be discovered incidentally in asymptomatic patients. For example, routine chest radiography may reveal a mediastinal mass or tracheal deviation.

The most common symptoms of substernal goiter result from compression of the trachea and/or esophagus and include dyspnea, choking sensation, cough, and dysphagia. [1] Progressive hoarseness, stridor, and superior vena cava syndrome are less common symptoms.

Hyperthyroidism may be observed in cervical or substernal goiters. Thyrotoxicity in goiters may be due to an autonomously functioning nodule or may be precipitated by ingestion of iodides found in certain expectorants or in radiographic contrast media.

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Physical Examination

In many cases in which discovery of a substernal goiter was made incidentally on imaging, the head and neck examination may be entirely normal.  In the event of tracheal narrowing, there may be stridor or audible biphasic respiration.

Indirect mirror or fiberoptic examination of larynx may be normal, or it may be associated with evidence of laryngotracheal deviation. Vocal cord paralysis is uncommon in the author's experience and would raise concern of malignancy. A substernal goiter may have a significant cervical component that is easily palpable, may have a palpable component only in the suprasternal area with the neck fully extended, or may be nonpalpable in neck.

The neck examination may also disclose deviation of the trachea from the midline; however, if the goiter is entirely substernal, tracheal deviation may not be evident on neck examination. A Pemberton maneuver can indicate the presence of superior vena cava syndrome: The maneuver is performed by having the patient elevate both arms until they touch each side of their face. [1] A positive Pemberton sign indicates compression at the thoracic outlet and is demonstrated by facial congestion, cyanosis, and/or respiratory compromise after 1 minute.

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