A 58-year-old woman with a longstanding goitre extending behind the sternum raises both arms above her head. Within 30 seconds she develops facial flushing, venous engorgement and mild cyanosis. This finding indicates obstruction at which site?

• A Thoracic inlet by the retrosternal extension of the goitre ✓
• B Left brachiocephalic vein by an intrathoracic tumour
• C Trachea by bilateral vocal cord palsy
• D Jugular venous valves by raised central venous pressure

Explanation

This is Pemberton's sign. Elevating the arms draws the thyroid and its soft tissue attachments into the rigid thoracic inlet, compressing the innominate veins and trachea when a retrosternal goitre occupies the inlet. Facial plethora and cyanosis within seconds to a minute confirm significant inlet obstruction and are an accepted indication for surgery even in an asymptomatic patient. Left brachiocephalic vein compression would not be reproduced by arm elevation alone.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.