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We report a case of intrathoracic goiter with positive Pemberton sign. Conventional spirometry did not show abnormalities, but arm elevation spirometry with flow-volume loops revealed expiratory flow limitation with a plateau. Clinicians should consider repeating flow-volume loops with arm elevation in all cases of intrathoracic goiter with initially normal loops.

Background: Retrosternal goiter is a common cause of compression of adjacent structures, and it may harbor cancer., Methods: During a 22-year period, we treated 44 patients with intrathoracic multinodular goiter., Results: The goiter was resected in 40 patients; 4 patients were rejected because of prohibitive risk. There were three minor complications and no deaths., Conclusions: The specific indications for resection include compression of adjacent structures, prevention of future complications, and obtaining a diagnosis. Fine-needle aspiration for diagnosis is not always possible and rarely reliable, and there is no effective medical therapy. Cervical incision is nearly always adequate, with few exceptions, such as very large posterior goiter, mediastinal blood supply, or carcinoma necessitating mediastinal dissection.

Large mediastinal cysts of the thyroid are rare and it is difficult to make a definitive tissue diagnosis prior to surgical removal. Ultrasonography and computed axial tomography are useful in documenting the cystic nature of the lesion and demonstrating its relationship to other mediastinal structures. These studies may also suggest the tissue of origin. We report a case of massive mediastinal thyroid cyst situated in the right posterior mediastinum and causing significant tracheal compression. Because of this unusual location and lack of iodine uptake, preoperative diagnosis was not possible. At surgery, which we performed via right thoracotomy because of the location of the mass, its origin from thyroid tissue was demonstrated. Resection was accomplished with care taken not to injure the recurrent laryngeal nerve. The patient recovered uneventfully.

Because of their tendency to progressively enlarge with compression of adjacent structures, as well as the small chance of malignancy, most intrathoracic goiters should be excised surgically. Most anterior substernal goiters and some ipsilateral posterior mediastinal goiters can be removed safely through a cervical incision. Large posterior mediastinal goiters, contralateral retrotracheal or retroesophageal posterior mediastinal goiters, and isolated mediastinal goiters with no significant cervical connection are best removed through a combined cervical and thoracic approach. The Lahey Clinic experience with three patients with posterior mediastinal goiter is described.