Many of the symptoms of multinodular goiter have already been described. They are chiefly due to the presence of an enlarging mass in the neck and its impingement upon the adjacent structures. There may be dysphagia, cough, and hoarseness. Paralysis of a recurrent laryngeal nerve may occur when the nerve is stretched taut across the surface of an expanding goiter, but this event is very unusual. When unilateral vocal cord paralysis is demonstrated, the presumptive diagnosis is cancer. Pressure on the superior sympathetic ganglions and nerves may produce a Horner's syndrome.

As the gland grows it characteristically enlarges the neck, but frequently the growth occurs in a downward direction, producing a substernal goiter. A history sometimes given by an older patient that a goiter once present in the neck has disappeared may mean that it has fallen down into the upper mediastinum, where its upper limits can be felt by careful deep palpation. Hemorrhage into this goiter can produce acute tracheal obstruction. Sometimes substernal goiters are attached only by a fibrous band to the goiter in the neck and extend downward to the arch of the aorta. They have even been observed as deep in the mediastinum as the diaphragm. Occasionally the skilled physician can detect a substernal goiter by percussion, particularly if there is a hint from tracheal deviation, or the presence of a nodular mass in the neck above the manubrial notch.

Symptoms suggesting constriction of the trachea are frequent, and displacement of the trachea is commonly found on physical examination. Roentgenographic examination is useful in defining the extent of tracheal deviation and compression. Compression is frequently seen but rarely is functionally significant. The authors have expected to find softened tracheal cartilage after the removal of some large goiters, but tracheomalacia has been observed only on the rarest occasion. Patients may be remarkably tolerant of nodular goiter even when the enlargement is striking. This finding is especially true in the endemic goiter areas of the world. On the other hand, when the facilities for removal are available, most patients like to be rid of their goiters.

It is generally agreed that, thyroid isotope or ultrasound scanning are of little or no use in the diagnosis of carcinoma in a multinodulair goiter 17b. Two aspects are important in the differentiation from malignancy. First, the clinical presentation. If the goiter is of longstanding, showing little or no growth, absence of a dominant node, familial, while there is no neck irradiation in the past, especially in childhood, no hoarse voice, and no suspicious lymphnodes in the neck, there is little fear for carcinoma. The second point is that if suspicion is present FNA cytology may be helpful.