Goitre ✅

🧑‍⚕️ Pemberton’s sign: Raising both arms above the head causes facial congestion, cyanosis, and respiratory distress due to obstruction of the thoracic inlet by a retrosternal goitre. A key bedside OSCE finding; positive in large substernal or mediastinal thyroid enlargement.

📖 About

• Goitre = enlarged thyroid gland (diffuse or nodular).
• WHO definition: thyroid lobes larger than the terminal phalanx of the patient’s thumb.
• Can be diffuse (uniform enlargement) or nodular (single or multinodular).
• May be euthyroid, hyperthyroid, or hypothyroid depending on aetiology.

⚡ Compression symptoms

• Tracheal compression: dyspnoea, cough, choking sensation, wheeze or stridor 🚨
• Retrosternal extension: pressure symptoms may worsen when lying flat or raising the arms.
• SVC compression: facial plethora, engorged neck/upper chest veins and Pemberton’s sign.
• Recurrent laryngeal nerve involvement: hoarseness or voice change - consider thyroid malignancy until excluded.
• Oesophageal compression: dysphagia or a sensation of food sticking.

⚡ Causes of Goitre

• Physiological: puberty and pregnancy, due to increased thyroid hormone demand.
• Autoimmune: Hashimoto’s thyroiditis and Graves’ disease.
• Iodine-related: iodine deficiency or excess.
• Inflammatory: subacute thyroiditis, including de Quervain thyroiditis.
• Drug-related / goitrogens: 💊 lithium, amiodarone and other goitrogenic agents.
• Smoking: 🚬 associated with thyroid enlargement and Graves’ orbitopathy.
• Nodular thyroid disease: multinodular goitre, solitary thyroid nodule or thyroid cyst.
• Neoplastic: thyroid adenoma or thyroid carcinoma, especially if hard, fixed or rapidly enlarging.
• Genetic / familial: familial goitre or inherited dyshormonogenesis.
• Idiopathic: no clear cause identified.

📑 Types of Goitre

• Diffuse non-toxic goitre: uniform thyroid enlargement, usually euthyroid; may cause tracheal or oesophageal compression if large.
• Diffuse toxic goitre: usually due to Graves’ disease; diffuse enlargement with biochemical hyperthyroidism.
• Nodular goitre: one or more discrete nodules; may be benign, cystic, inflammatory or malignant.
• Multinodular goitre: multiple thyroid nodules; may be non-toxic or toxic if autonomous hormone production develops.
• Retrosternal goitre: thyroid enlargement extending below the thoracic inlet; more likely to cause dyspnoea, stridor, dysphagia or SVC-type symptoms.

📏 WHO Grading of Goitre

• Grade 0: Not palpable or visible
• Grade 1: Palpable, not visible in neutral neck; includes small nodules
• Grade 2: Clearly visible swelling in neutral neck

🚩 Malignancy High-Risk Features

• Rapid growth or hard, fixed nodule
• Hoarseness (recurrent laryngeal nerve involvement)
• Cervical lymphadenopathy
• History of head/neck irradiation
• Thyroid cancer in first-degree relative
• MEN2 syndrome / elevated calcitonin
• FDG-PET avidity on incidental imaging

🩺 Clinical Examination

• Inspect from front & behind: neck contour, asymmetry, tracheal deviation.
• Palpate thyroid and cervical lymph nodes; assess nodularity, consistency, tenderness.
• Ask patient to swallow: thyroid moves upwards with swallowing.
• Listen for bruit (Graves’ disease).
• Check voice: hoarseness → recurrent laryngeal nerve compression.
• Assess for compressive symptoms: dyspnoea, dysphagia, stridor.
• Perform Pemberton’s manoeuvre if retrosternal extension suspected.
• Evaluate thyroid function signs: hypo- or hyperthyroid features.

🔬 Investigations

• Bloods: FBC, U&E, CRP (infection or inflammation)
• TFTs: TSH, free T4, T3. Hashimoto: ↑TSH; Graves: ↓TSH, ↑T3/T4
• Autoantibodies: Anti-TPO, Anti-Tg; TSH receptor antibodies for Graves’ disease
• Imaging:
  • Ultrasound: first-line for morphology, nodule characterization, FNA guidance
  • Radionuclide scan: if TSH suppressed (hot vs cold nodules)
  • CT thoracic inlet / MRI: for retrosternal or mediastinal extension; use non-contrast to avoid iodine load if future RAI planned

🔍 FNA Indications (Nodules)

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

💊 Management (NICE-compliant)

• Rule out malignancy: USS ± FNA
• Observation: small, asymptomatic benign goitres; annual clinical review
• Iodine supplementation: if deficiency suspected (esp. endemic areas)
• Medical therapy:
  • Thyroxine suppression rarely used; antithyroid drugs (Carbimazole, Propylthiouracil) for toxic goitre
• Radioactive iodine: indicated for toxic diffuse or multinodular goitre
• Surgery: for suspected malignancy, compressive symptoms, cosmetic concern, or failed medical therapy; total or hemithyroidectomy depending on disease
• Monitor airway and postoperative complications (haematoma, hypocalcaemia, RLN injury)

Cases - Goitre (Thyroid Enlargement)

• Case 1 - Multinodular Goitre with Compressive Symptoms 🦴: 68F, neck swelling, intermittent dysphagia, hoarseness. Irregular nodular thyroid, retrosternal extension, tracheal deviation on CXR. TFTs normal. Management: Surgical thyroidectomy, airway monitoring, histology to exclude malignancy.
• Case 2 - Diffuse Toxic Goitre (Graves’) 🔥: 32F, weight loss, heat intolerance, tremor, palpitations. Smooth diffuse goitre with bruit; exophthalmos, pretibial myxoedema. TFTs: TSH suppressed, T3/T4 elevated; TRAb positive. Management: Antithyroid drugs, β-blockers; consider RAI or surgery if relapse; ophthalmology review.
• Case 3 - Endemic Simple Goitre 🌍: 19F, large painless diffuse thyroid, no eye or compressive signs. Low dietary iodine; TFTs normal. Management: Iodine supplementation, dietary education; surgery if very large or disfiguring.

Teaching Commentary 🧠

Goitre assessment integrates function, structure, and compression. - Diffuse: Graves’ (hyperthyroid), Hashimoto’s (hypothyroid), simple/iodine deficiency (euthyroid). - Nodular: multinodular goitre, solitary nodule (benign vs malignant). Red flags: rapid growth, hard/irregular nodule, cervical lymphadenopathy, hoarseness → FNA ± surgery. NICE-compliant management: targeted investigation, risk stratification, stepwise intervention (observation → medical → RAI → surgery) with monitoring of airway and thyroid function.