Pressure of the enlarged Gland
	- Trachea
	– Recurrent laryngeal nerve
	– Oesophagus
	– Big vessels

Fig. 6 - A big goitre can cause pressure symptoms

Important points to note are size, surface, fixity (infiltration into vascular structures/muscles), tenderness, lymph nodes and retrosternal extension. Indirect laryngoscopy is of immense value to visualize the movements of the vocal cords for diagnosis of recurrent laryngeal nerve palsy as well as for documentation of vocal cord movement before surgery (injury to the nerve is a well recognised complication of thyroidectomy). Investigations for the structural problem will depend on the clinical findings. A lateral X-ray of the neck may be good to see the tracheal air shadow but better documentation can be done by CT scanning which is a wonderful tool to visualize an intrathoracic goitre (Fig.7).

Fig. 7 - CT scan of chest showing large Intrathoracic Goitre

Barium swallow is an useful tool to see compression on the oesophagus. Ultrasound of the thyroid is helpful to differentiate a cyst from a thyroid nodule (single or multiple). Isotope scan of thyroid gland helps to localise ectopic thyroid (lingual thyroid, intrathoracic goitre, etc).

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