Goiter, upper airway obstruction and the flow-volume loop

The thyroid gland is located across the front of the upper airway a short distance below the larynx. An enlarged thyroid gland is known as a goiter. The most common worldwide cause of goiter is an iodine deficiency. This is much less common in the western nations where factors such as Hashimoto’s thyroiditis, Graves’ disease, multi-nodular thyroid disease, thyroid cancer, pregnancy and the side effects of some medications are the its primary causes. Common respiratory complaints associated with goiter include cough, hoarseness, shortness of breath and stridor.


[illustration from HealthyThyro.com]

When a goiter is large enough it can press against the trachea and cause a narrowing or deviation of the upper airway. My lab usually gets at least a couple of patients referred to us every year with a diagnosis of goiter and a request that we assess whether it is causing any significant airway obstruction. Decades ago I was taught by my medical director that when this occurs it shows up as an expiratory plateau on a flow-volume loop.


The reality (as usual) is more complex and this is mostly because the thyroid gland lies close to the boundary between the extrathoracic and intrathoracic sections of the trachea. Depending on its size and the which direction the thyroid expands towards, goiter can show up as an extrathoracic or intrathoracic airway obstruction. Even more importantly, as a recent article in Chest showed, the airway obstruction from goiter can be dependent on body position as well.

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