A goiter (alternative spelling: goitre) extending behind the sternum or breast bone. Referred to as a "retrosternal" goiter in the UK; it might also be termed "intrathoracic" (inside the chest), perhaps if its widest part is below the sternal notch.

The Pemberton maneuver (which see) may betray the presence of such a goiter. The Valsalva maneuver is worth a try. Lying on the back with a cushion underneath the shoulders so that the head is back may produce the goiter into the neck. And the Valsalva maneuver could be used at the same time to try and "blow" the thing into the neck - Sporus does not know, but this sounds as though you could do yourself in - perhaps exercise caution. It is easier to feel the gland in the neck if water is sipped. An innability to discover the base of the thyroid gland is suggestive of a substernal goiter.

It has usually appeared because one of the lower poles of the gland, which is rather given to enlarging, has, instead of growing forward to give a conventional goiter, grown backwards and down the neck into the top of the chest. However other parts of the gland may enlarge or the gland might be in the wrong place congenitally. These goiters can become very large, they may even grow as far down as the diaphragm, weigh several kilograms and do things like pressing on the heart - which may make it beat fast - (slow beating caused by the goiter pressing on the vagus nerve is more common). Sporus does not know but gets the impression that the common idea goiters get larger as people get older may be innaccurate.

It is often diagnosed from a chest X-ray taken for another reason (Sporus has read: "a history of low dose medical X-rays" increases the probability of a goiter turning cancerous to not by 40%). X-rays show the goiter in 75% of cases, ultrasound scans in 15% of cases, a computerized tomography, CT, scan is allegedly always successful. The impression is easily gained that these goiters are heavily under diagnosed.

Many of the symptoms of a substernal goiter are due to its pressing on various structures: Pressure on the veins that drain the head and arms causes their blood supply to be compromised. This may cause dilation of the veins in the cervix (neck), face or chest; they may stand out like varicose veins. Rarely, there may be superior vena cava syndrome (SVCS). There may be trouble swallowing (dysphagia). The victim might go blind or feel faint, due to pressure on blood vessels, when they swallow. Slight hoarseness or a cough are possible, as are voice problems due to pressure on the recurrent laryngeal nerve. (In Sporus's view it is perhaps possible for speech problems to be present due to the voice competing with the brain for the already compromised blood supply. In this case speech might be tiring - also a well known symptom of myasthenia gravis - or might produce a feeling of a poor blood supply to the head.) The normal symptoms of a thyroid disorder may occur. Pressure on the trachea, or even competing with the lungs for space in the thorax, may cause breathing difficulty (dyspnea): this can become suddenly severe and dangerous during a respiratory infection or due to bleeding into a blood filled cyst inside the goiter (or - a speculation - the stomach may become very full with pabulum, drink or gas and lift the diaphragm which lift the lungs so that they compete with the goiter for an even smaller space inside the thorax. Thus, for example, difficulty inflating the lungs after a large meal may be suggestive.) Dyspnea may be present during sleep or when the head is in one particular position. Other pressure symptoms may vary with the position of the head, for example faintness when looking upward. There may be stiffness of the neck.

It is impossible to overstate, in diagnosing this problem and in everything else, the incompetence and venality of the medical profession.

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