Pemberton’s Sign in Patient with Substernal Goiter

Abstract

A 62-yr-old man with a long history of goiter was referred to the physician due to progressive dyspnea and stridor on exertion. The patient has slept on his left side to improve breathing. Physical examination revealed an enlarged left lobe of the thyroid, but a lower pole was not palpable. After elevation of both of his arms, marked facial plethora developed, indicating compression of the jugular veins (Pemberton’s sign) (Fig. 1, A and B). The patient was euthyroid. Noncontrast computed tomography of the neck revealed a large goiter of the left thyroid lobe and isthmus, with longitudinal diameter 11 cm, transversal 6.5 cm, and anteroposterior 5 cm. The left common carotid artery and jugular vein were dislocated laterally and posterior. Tracheal stenosis was present at the level of the thoracic inlet. The patient was sent to surgery and successfully operated. Total thyroidectomy was performed. Pathohistology revealed nodular colloid goiter. Pemberton’s sign may be found in patients with a large mediastinal mass, usually with large retrosternal goiter (1, 2) or tumor. Hugh Spear Pemberton described the sign in a letter to Lancet in 1946 (3). Although contrast-enhanced computed tomography provides better visualization of neck and mediastinal structures, it may be contraindicated in patients with large goiter because the use of iodinated radiographic contrast agents may provoke iodine-induced hyperthyroidism (4). The Pemberton maneuver should be used as an addition to physical examination of substernal goiter, especially in patients with symptoms of compression. This sign indicates compression of vascular structures in the thoracic inlet that warrants more urgent treatment. Acknowledgments