goiter and choking

Q: 53 years old female presented with progressively worsening choking sensation over months. On exam, noticed to have stridor. CT chest and neck confirmed the diagnosis of substernal goiter. At this point, the probability of having symptomatic obstruction is less than? - select one

A) 8 mm

B) 15 mm

Answer: A

This question aims to highlight that once cervical or substernal thyroid goiter becomes symptomatic, the margin of safety drastically narrows. The patient largely remains asymptomatic or may report mild symptoms until the tracheal diameter becomes less than 8 mm. Moreover, as the tracheal luminal diameter becomes less than 5 mm, the chances of a high-grade complication become high, with stridor or wheezing at rest.

Other major complications of such goiter include the development of severe acute pain, which may signify hemorrhage into a nodule. 

Fortunately, these goiters are very slow to expand, and most patients, more females, are in their fifth or sixth decades of life.

Exertional and/or positional dyspnea occurs whenever the thyroid moves into the thoracic inlet. This mostly occurs in bending.

Other symptoms are progressive cough, choking sensation, dysphagia, compression of the recurrent laryngeal nerve causing vocal cord palsy and hoarseness, phrenic nerve paralysis, Horner's syndrome, and, in severe cases, jugular vein compression and/or thrombosis, cerebrovascular steal syndromes, and/or superior vena cava syndrome.

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References:

1. Al-Bazzaz F, Grillo H, Kazemi H. Response to exercise in upper airway obstruction. Am Rev Respir Dis 1975; 111:631.

2. Shaha AR, Burnett C, Alfonso A, Jaffe BM. Goiters and airway problems. Am J Surg 1989; 158:378.

3. Torres A, Arroyo J, Kastanos N, et al. Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter. Crit Care Med 1983; 11:265.

4. Banks CA, Ayers CM, Hornig JD, et al. Thyroid disease and compressive symptoms. Laryngoscope 2012; 122:13.