SHM Converge Scientific Abstract ePoster Gallery-Beware of the Loitering Goiter

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This case describes an 82-year-old woman with dementia, Graves’ disease, chronic kidney disease, hypertension, diabetes, peripheral arterial disease, heart failure with preserved ejection fraction, and a recent right internal jugular thrombus treated with apixaban. She presented with worsening bilateral arm swelling and new right facial swelling, without dyspnea, dysphagia, or voice change.<br /><br />Imaging showed an unchanged right IJ thrombus on ultrasound, but chest imaging revealed a more important finding: severe narrowing of the bilateral brachiocephalic veins with collateral chest wall flow, plus a multilobulated substernal goiter extending into the superior mediastinum and causing mild tracheal compression. These findings explained an SVC-like syndrome.<br /><br />The discussion emphasized that substernal goiter is thyroid enlargement extending below the sternal notch into the mediastinum. It is usually seen in older women, often found incidentally, and can slowly enlarge enough to compress the trachea, esophagus, and major veins. SVC-like symptoms from substernal goiter are uncommon, occurring in roughly 2–19% of patients.<br /><br />Definitive treatment is complete thyroidectomy, and recurrence is nearly zero when surgery is prompt and successful. However, this patient was a poor surgical candidate. Other options discussed included thyroid artery embolization, which may take time to work, and bilateral brachiocephalic vein stenting as a temporary measure. She was ultimately discharged for outpatient evaluation for radioactive ablation.<br /><br />The key teaching point is to broaden the differential for superior vena cava syndrome and consider substernal goiter as a rare but important cause of neck and facial swelling, particularly in older patients with known thyroid disease.

Asset Subtitle

Alexandra Lee

Meta Tag

Author List Alexandra Lee, Mary-Nel Saarloos

Category Clinical Vignettes

Concept Superior Vena Cava Syndrome

Concept Substernal Goiter

Concept Thyroidectomy

Concept Differential Diagnosis

Concept Mediastinum

Distinguished Non-Finalist

Presenter Organization Duke University Hospital

Presenting Author Alexandra Lee

Track Adult

Keywords

substernal goiter

superior vena cava syndrome

brachiocephalic vein stenosis

neck swelling

facial swelling

thyroid enlargement

mediastinal mass

tracheal compression

Graves disease

thyroidectomy

Superior Vena Cava Syndrome

Substernal Goiter

Thyroidectomy

Differential Diagnosis

Mediastinum