Physical Examination

In general, the size of a smaller goiter is overestimated, whereas the size of larger goiters is underestimated. Thyroid enlargement is often best observed when the patient swallows. A visible goiter has usually reached a size of 30 to 40 mL (=1.5- to 2-fold increase in the size of a normal thyroid gland). One should determine whether the thyroid gland is symmetrical or a solitary nodule, a multinodular goiter, or a dominant nodule in a multinodular goiter. Does the goiter move with swallowing, or is the goiter fixed? Are the nodules hard, firm, or soft? Is there associated lymphadenopathy?

One should also determine whether there is any tracheal deviation. As previously mentioned, one can document whether there is venous obstruction by having the patient elevate his or her arms above the head. If the neck veins become prominent or the face become flushed, this is a positive Pemberton sign.6061

One should also evaluate the patients for signs of hypothyroidism, hyperthyroidism, or possible other medical disorders. Features that suggest malignancy include vocal cord paralysis, fixed firm nodules, or associated lymphadenopathy.62 Occasionally, a patient with recurrent laryngeal nerve palsy can have a benign nodule.63

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