Prepared by: ZYRINE M.

SALOMON
PEMBERTONS SIGN:
Pemberton's sign was named after Dr. Hugh Pemberton, who characterized it in 1946, The
Pemberton maneuver is a physical examination tool used to demonstrate the presence of latent pressure
in the thoracic inlet. The maneuver is achieved by having the patient elevate both arms until they touch
the sides of the face. A positive Pemberton's sign is marked by the presence of facial congestion and
cyanosis, as well as respiratory distress after approximately one minute.
A positive Pemberton's sign is indicative of superior vena cava syndrome (SVC), commonly the result of a
mass in the mediastinum. Although the sign is most commonly described in patients with substernal
goiters where the goiter corks off the thoracic inlet, the maneuver is potentially useful in any patient with
adenopathy, tumor, or fibrosis involving the mediastinum.
SVC has been observed as a result of diffuse mediastinal lymphadenopathy of various pathologies such
as cystic fibrosis and Castlemans disease. Park et al.reported enlarged cervical lymph nodes associated
with hemophagocytic lymphohistiocytosis as the cause of internal jugular vein compression, which
presented clinically similar to SVC syndrome.
More recently, Tipton et al. described a patient with diffuse mediastinal lymphadenopathy due to
amyloidosis. The unique configuration of enlarged lymph nodes resulted in a positive Pemberton's
Sign. Not surprisingly, apical lung cancers may cause a positive Pemberton's sign and a high index of
suspicion should be maintained in patients with symptoms of dyspnea and facial plethora with an
extensive smoking history.
MANIFESTATION:
Substernal goiter with obstruction on inlet of neck and, argely vascular venous return problems with neck
certain maneuvers; seen also with upper mediastinal masses and apical lung tumors as well as thoracic
aortic aneurysm. This is manifest with arms held upward close to the head on both side and observing
plethora of the face and distended neck and scalp veins. Next comes cyanosis regionally with distress
worsened by valsalva maneuver.
DIAGNOSTIC EXAMS:
Clinical, biochemical, and radiological assessments
TREATMENT:
Treatment options for goitre depend on the cause and the clinical picture and may include observation,
iodine supplementation, thyroxine suppression, thionamide medication (carbimazole or propylthiouracil),
radioactive iodine ablation and surgery.
NURSING MANAGEMENT:

Ask the patient to lift both arms as high as possible.

Watch the patient's face for signs of congestion - plethora - and cyanosis. Respiratory distress
and inspiratory stridor may occur. Venous congestion may be apparent as distension of the neck
veins.

Listen for stridor whilst the patient takes in a deep breath. This is a test for thoracic inlet
obstruction due to a retrosternal goitre or any other causes including lung carcinoma, other
tumors - lymphomas, thymomas, dermoid cysts - or an aortic aneurysm.

INSIGHT:
Pemberton's sign is used to evaluate venous obstruction in patients with goiters. The sign is positive
when bilateral arm elevation causes facial plethora. It has been attributed to a "cork effect" resulting from
the thyroid obstructing the thoracic inlet, thereby increasing pressure on the venous system. According to
some, the "cork effect" is caused by the thyroid descending into the thoracic inlet during arm elevation.
According to others, the obstruction is due to elevation of the thoracic inlet against the thyroid. When
eliciting Pemberton's sign, facial plethora and venous engorgement were due to the clavicles moving and
compressing venous vasculature against the enlarged thyroid and not to a "cork effect." Rather, the
clavicular motion observed during arm elevation could be compared to the movement of a "nutcracker"
compressing major venous structures within a narrowed thoracic inlet against a relatively fixed and
enlarged thyroid. The pemberton maneuver is an important physical examination tool to demonstrate
venous obstruction or latent pressure in thoracic inlet and should be performed in every patient with
suspected neck compression.