substernal goiter

Q; 52 years old female from Denmark* presented to ED with sudden enlargement of her known substernal goiter associated with pain. A bedside ultrasound followed by a CT scan confirmed hemorrhage into a goiter. Substernal goiter enlargement tends to do more of what? - select one

A) dysphagia 

B) stridor

Answer: B

Dysphagia is less common in substernal goiter because the esophagus is posteriorly located. An obstructive cervical or substernal goiter can enlarge and press on the trachea; when the tracheal lumen is less than 5 mm, stridor or wheezing at rest is expected. It would be prudent to secure the airway before relieving compression in acute cases. An experienced anesthesiologist should be called, as the margin of error is small.

Other symptoms which may occur are compression of a recurrent laryngeal nerve causing transient or permanent vocal cord palsy, manifesting as hoarseness, phrenic nerve paralysis, Horner's syndrome due to compression of the cervical sympathetic chain, and, in a few cases, jugular vein compression or thrombosis, cerebrovascular steal syndromes, or the superior vena cava syndrome.

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#endocrinology

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References:

1. O’Connor, Eoin, Looney, Michael, Lennon, Emma - Massive retrosternal goitre causing stridor and respiratory distress—a case report - Journal of Emergency and Critical Care Medicine - Vol 9 (March 30, 2025) /, https://jeccm.amegroups.org/article/view/8867

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

3. Aragón Valera C, Antón Bravo T, Sanchón Rodríguez R, Martínez Bermejo E, Paniagua Ruiz A, Alvarez Santirso R. Dyspnea and stridor due to multinodular goiter in an obese woman. Endocrinol Nutr. 2008 May;55(5):234-6. English, Spanish. doi: 10.1016/S1575-0922(08)70674-0. Epub 2008 Oct 15. PMID: 22967919.

*Denmark epidemiology is consistent with mild-to-moderate iodine-deficient goiter.