Makindo Medical Notes

🧑‍⚕️ Pemberton’s sign: Raising both arms above the head causes facial congestion, cyanosis, and distress due to external jugular venous obstruction as the goitre is drawn into the thoracic inlet. A key bedside OSCE finding.

📖 About

• Goitre = an enlarged thyroid gland.
• WHO definition: thyroid lobes larger than the terminal phalanx of the patient’s thumb.
• Can be diffuse or nodular (single or multinodular).

⚡ Causes of Goitre

• Idiopathic
• Hashimoto’s thyroiditis
• Graves’ disease
• Puberty / pregnancy (physiological)
• Iodine deficiency
• Subacute thyroiditis
• Goitrogens (💊 Lithium, Amiodarone, 🚬 smoking)

📑 Types

• Diffuse nontoxic goitre: Uniform enlargement, often euthyroid.
• Nodular / Multinodular goitre: Gland enlarged with nodules; may cause compressive symptoms on trachea/oesophagus.

📏 WHO Grading

• Grade 0: No palpable or visible goitre.
• Grade 1: Palpable but not visible in neutral neck. Includes small nodules in an otherwise normal-sized gland.
• Grade 2: Clearly visible swelling of thyroid in neutral neck.

🚩 Malignancy High-Risk Features

• History of head/neck irradiation
• Thyroid cancer in a first-degree relative
• Childhood radiation exposure
• FDG-PET uptake
• MEN2 syndrome, ↑ calcitonin

🩺 Clinical Examination

• Inspect from front & behind: appearance, position, respiratory compromise.
• Goitre may be asymptomatic (cosmetic only) OR cause compressive symptoms (cough, dysphagia, stridor).
• Check for features of hypo- or hyperthyroidism.
• Palpate for local lymphadenopathy.
• Ask patient to swallow: thyroid moves up with swallow.
• Check voice for hoarseness (recurrent laryngeal nerve involvement).
• Pemberton’s sign if retrosternal extension.

🔬 Investigations

• Bloods: FBC, U&E, CRP
• TFTs: TSH & T4. (Hashimoto’s → ↑TSH; Graves’ → ↓TSH)
• If TSH suppressed → Radionuclide scan for “hot” vs “cold” nodules
• Autoantibodies: Anti-TPO, Anti-TG
• Ultrasound: First-line imaging; guides FNA/biopsy of suspicious nodules.
• CT thoracic inlet: For retrosternal extension; order non-contrast (iodine load risk).

🔍 Nodules to Biopsy (FNA Indications)

• Any suspicious nodule + cervical lymphadenopathy
• High-risk history: ≥5 mm
• Microcalcification: >1 cm
• Solid: >1 cm
• Mixed cystic-solid: >1.5–2 cm
• Spongiform: >2 cm
• Pure cystic: No FNA required

💊 Management

• Exclude malignancy → USS + FNA where indicated.
• Observation: small, asymptomatic, benign goitres.
• Iodine supplementation (if deficient).
• Medical therapy: thyroxine suppression (rarely now), antithyroid drugs (Carbimazole, Propylthiouracil).
• Radioactive iodine ablation: for toxic goitre.
• Surgery: indicated if malignancy suspected, compressive symptoms, cosmetic concern, or failure of other therapies.