🧑‍⚕️ 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.

Cases — Goitre (Thyroid Enlargement)

Case 1 — Multinodular Goitre with Compressive Symptoms 🦴: A 68-year-old woman presents with neck swelling, intermittent dysphagia, and hoarseness. Exam: irregular, nodular thyroid enlargement extending retrosternally, tracheal deviation on CXR. TFTs: normal. Diagnosis: Euthyroid multinodular goitre with compressive symptoms. Management: Surgical thyroidectomy (due to compressive features); monitor airway; histology to exclude malignancy.
Case 2 — Diffuse Goitre in Graves’ Disease 🔥: A 32-year-old woman complains of weight loss, heat intolerance, tremor, and palpitations. Exam: smooth, diffuse goitre with bruit; exophthalmos; pretibial myxoedema. TFTs: suppressed TSH, elevated T3/T4; TSH receptor antibodies positive. Diagnosis: Diffuse toxic goitre (Graves’ disease). Management: Antithyroid drugs (carbimazole/propylthiouracil), consider radioiodine or surgery if relapse; β-blockers for symptoms; ophthalmology review.
Case 3 — Endemic Simple Goitre 🌍: A 19-year-old girl from a mountainous region presents with a large, diffuse, painless thyroid swelling. Exam: no eye signs, no compressive features. TFTs: normal. Dietary history: low iodine intake. Diagnosis: Simple goitre due to iodine deficiency. Management: Iodine supplementation, dietary education; thyroidectomy if very large or disfiguring.

Teaching Commentary 🧠

Goitre = enlarged thyroid, diffuse or nodular. - Diffuse: Graves’ (hyperthyroid), Hashimoto’s (hypothyroid), simple (iodine deficiency). - Nodular: multinodular goitre, solitary nodule (benign vs malignant). Always assess function (TFTs), structure (ultrasound ± FNA), and compression symptoms. ⚠️ Red flags: rapid growth, hard/irregular, cervical nodes, hoarseness → suspect malignancy.

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Goitre