CASE REPORT

https://doi.org/10.5005/jp-journals-10002-1434
World Journal of Endocrine Surgery
Volume 14 | Issue 2 | Year 2022

A Giant Goiter Challenge

Ram Shankar Renganathan1, Mohammed Ibrahim M2, Sai Selvendrakumar VG3

1Department of Otorhinolaryngology, ESIC Hospital, Tirunelveli, Tamil Nadu, India

2Department of Surgical Oncology, ESIC Hospital, Tirunelveli, Tamil Nadu, India

3Department of Anaesthesiology, ESIC Hospital, Tirunelveli, Tamil Nadu, India

Corresponding Author: Ram Shankar Renganathan, Department of Otorhinolaryngology, ESIC Hospital, Tirunelveli, Tamil Nadu, India, Phone: +91 8807795943, e-mail: ramshankar03@gmail.com

Received on: 02 September 2022; Accepted on: 10 February 2023; Published on: 15 April 2023

ABSTRACT

Introduction: Goiter (derived from the Latin word gutter-throat)1 is a noncancerous palpable enlargement of the thyroid gland. The enlargement, if it exceeds the upper limit of the normal defined volume, is pathological. Goiter is a manifestation of deficient thyroid hormone production due to iodine (I) deficiency. Here we report a case of a very large endemic multinodular goiter and its management in a secondary care hospital.

Case description: A 52-year-old female reported to the outpatient department with swelling in her neck for the past 30 years. On examination, there was a huge swelling in the neck extending superiorly up to the floor of the mouth, inferiorly up to the sternum and pendulous over the sternum with no intrathoracic extension. Ultrasound revealed a heterogeneous echotexture of the gland with multiple nodules. Computed tomography revealed a heterogeneously enhancing enlarged thyroid with no calcification with mild tracheal compression. Fine needle aspiration cytology revealed adenomatous hyperplasia in nodular goiter. Blood triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) levels are within normal limits. Upper gastrointestinal (GI) endoscopy was done, which revealed a postcricoid web. It was managed with bougie dilators under endoscopic guidance. A decision to do a total thyroidectomy was made in view of dysphagia and the chance of containing hidden malignancy. The intubation was smooth. A Gluck Sorenson incision was made, and dissection proceeded like a total thyroidectomy. The strap muscles were retracted laterally and not divided. Left lobe dissection was started, the gland was brought out of the wound, and the carotid artery and internal jugular vein were delineated. A recurrent laryngeal nerve was identified between the carotid artery and trachea and was traced up to the cricothyroid muscle on both sides. Parathyroid was identified and preserved on both sides. The thyroid gland was separated from the trachea dividing Berry’s ligament, and removed in toto. There was minimal tracheomalacia. The wound was closed in layers with surgical drains. The patient was extubated the next day. Her voice was normal, and serum calcium was within normal limits on the next postoperative day. On postoperative day 2, patient developed transient hypocalcemia. The same was managed with oral calcium supplements and intravenous (IV) calcium boluses. The patient was discharged home on the 7th postoperative day.

Discussion: Adequate blood reservation should be made if transfusion is necessary during or after surgery. Availability of ventilator facilities should be ensured before taking these patients for surgery. During intubation, a difficult airway should be anticipated, and an awake fiberoptic intubation facility should be ready in the operating room. Controlled hypotension during anaesthesia may be necessary for the reduction of overall blood loss and improved surgical field conditions.4 It would be ideal to have a nerve monitor in managing these cases, but we could demonstrate recurrent laryngeal nerve without it.7 The excess skin need not always be removed as it is stretched skin due to the swelling and returns to its original size after thyroid gland removal. The patient was extubated the next day in view of tracheomalacia. The patient was supplemented with a replacement dose of T4 the next day. The histopathological report was a colloid goiter.

Conclusion: This huge goiter is preventable and could have been managed early. The intraoperative challenges with these huge goiters are distorted anatomy, bleeding and injury to vital structures, namely the trachea, esophagus, and great vessels. For huge goiters, we advocate Gluck Sorenson incision, no division of strap muscles, and no excision of the excess neck skin. Tracheomalacia and occult malignancy were the main concerns with this long-standing large goiter.8

How to cite this article: Renganathan RS, Ibrahim MM, Selvendrakumar SVG. A Giant Goiter Challenge. World J Endoc Surg 2022;14(2):58-62.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Colloid goiter, Computed tomography, Follicular carcinoma, Thyroid.

INTRODUCTION

Goiter (derived from the Latin word gutter-throat)1 is a noncancerous palpable enlargement of the thyroid gland. The enlargement, if it exceeds the upper limit of the normal defined volume, is pathological. This may simply be described as 18 mL for women and 25 mL for men.2 For screening purposes, if the thyroid gland is larger than the terminal phalanx of the thumb of the person examined, he should be referred to the specialist.3 The most common cause of goiter is I deficiency. It is endemic in populations where the I intake is <10 µgm/day.3 Goiter is a manifestation of deficient thyroid hormone production due to I deficiency. The gland is subjected to excess TSH stimulation causing thyroid hyperplasia and an increase in vascularity to maintain a euthyroid state in these patients.1 Though goiters are common, huge goiters are uncommon, and it is challenging for surgeons to manage such cases, given the enormity of the size of the gland and the distorted anatomy of the adjacent structures. Here we report a case of a very large endemic multinodular goiter and its management in secondary care hospital.

CASE DESCRIPTION

A 52-year-old female reported to the outpatient department with swelling in her neck for the past 30 years. It was insidious in onset and progressively increased in size with no compressive or obstructive symptoms except recent onset dysphagia. She had difficulty in flexion the neck and a sense of neck tightness. She has no past medical or surgical ailments and no similar illness in her family. On examination, there was a huge swelling in the neck extending superiorly up to the floor of the mouth inferiorly up to the sternum and pendulous over the sternum with no intrathoracic extension (Figs 1 and 2). Distended veins were seen over the swelling. The right lobe was larger than the left. It was firm in consistency. The surface had multiple lobulations. Both carotid arteries were palpable, and the pulsations were laterally displaced. Trachea was not palpable below the swelling. The swelling moves upward with deglutition. No bruit was heard on auscultation of the swelling. Ultrasound revealed heterogeneous echotexture of the gland with multiple nodules. Computed tomography revealed a heterogeneously enhancing enlarged thyroid with no calcification with mild tracheal compression (Fig. 3). Fine needle aspiration cytology revealed adenomatous hyperplasia in nodular goiter. Blood T3, T4, and TSH levels are within normal limits. Upper GI endoscopy was done, which surprisingly revealed a postcricoid web as we suspected compression of the esophagus as a cause of her dysphagia. It was managed with bougie dilators under endoscopic guidance, and the dysphagia got relived. Indirect laryngoscopy revealed structurally normal mobile vocal cords. Preoperative hemoglobin was 7.3 mg%, and the same was corrected by blood transfusions and iron supplements.

Fig. 1: Front view

Fig. 2: Lateral view

Fig. 3: Computed tomography neck

A decision to do a total thyroidectomy was made in view of aesthetic concerns and the chance of containing hidden malignancy. Difficult intubation was anticipated, but on the contrary, the intubation was smooth. A nasogastric tube was inserted. A Gluck Sorenson incision was made, the subplatysmal flap was elevated, and dissection proceeded like total thyroidectomy. The strap muscles were lax and thinned out. The strap muscles were retracted laterally and not divided. A huge thyroid swelling was seen, with the superior pole reaching the floor of the mouth and inferiorly up to the sternum. Left lobe dissection was started, the gland was brought out of the wound, and the carotid artery and internal jugular vein were delineated. Anatomical landmarks were grossly distorted. Subcapsular veins were distended, and bleeding vessels were clamped and cut using a harmonic scalpel. The recurrent laryngeal nerve was identified between the carotid artery and trachea and was traced up to the cricothyroid muscle. The superior pole vessels were individually dissected, clamped, cut, and suture ligated.

The dissection of the right lobe was started, and the gland was dissected from the carotid artery. The right recurrent laryngeal nerve was identified and traced upwards. The thyroid gland was separated from the trachea dividing Berry’s ligament, and removed in toto. Parathyroid was identified and preserved on both sides. There was minimal tracheomalacia. The wound was closed in layers with surgical drains. The patient was extubated the next day. Her voice was normal, and serum calcium was within normal limits on the next postoperative day. On the second postoperative day, the patient developed transient hypocalcemia with a serum calcium of 6.9 mg%. The same was managed with oral calcium supplements and IV calcium boluses. Drains were removed on 4th day of surgery. The patient was discharged home on the 7th postoperative day.

DISCUSSION

Management of giant goiter requires proper preoperative planning, good intraoperative dissection and scrupulous postoperative care. Indirect laryngoscopy is essential to rule out any vocal cord palsy due to compression or infiltration of recurrent laryngeal nerve. Preoperatively, hemoglobin levels are checked and if low should be corrected. Adequate blood reservations should be made if transfusion is necessary during or after surgery. Availability of ventilator facilities should be ensured before taking these patients for surgery. During intubation, a difficult airway should be anticipated, and an awake fibreoptic intubation facility should be ready in the operating room. Controlled hypotension during anaesthesia may be necessary for the reduction of overall blood loss and improved surgical field conditions.4

The transverse collar skin crease incision routinely used in thyroid surgery was not useful in this case because those incisions limit the exposure superiorly. Many authors advocate the same transverse collar incision used in routine thyroidectomy for giant goiters.5,6 Here Gluck Sorenson incision similar to a laryngectomy was made. (Fig. 4)

Fig. 4: Incision

The subplatysmal flap was elevated, and the strap muscles were thinned out and draped over the gland (Fig. 5). Here, we did not divide the strap muscles, but we retracted it as it was lax and was able to expose the whole thyroid.

Fig. 5: Thinned-out strap muscles

The dissection proceeded like routine thyroidectomy, but there were multiple bleeders, which were managed with bipolar cautery, harmonic scalpel and surgical ties. The recurrent laryngeal nerve could be delineated on both sides though anatomical landmarks were distorted (Fig. 6). It would be ideal to have a nerve monitor to confirm the functional integrity of recurrent laryngeal nerve in managing such complicated cases.7,8

Fig. 6: Recurrent laryngeal nerve

After the removal of the gland, there was minimal tracheomalacia, and the wound was closed in layers with surgical drains (Fig.7). The excess skin need not always be removed as it is stretched skin due to the swelling and returns to its original size after thyroid gland removal. The patient was extubated the next day in view of tracheomalacia. Tracheomalacia can occur at any time after surgery and cause airway obstruction. Hence it is advisable to retain the endotracheal tube postoperatively for at least 24 hours.

Fig. 7: Closure

The gland was 30 × 27 cm and weighed 510 gm (Figs 8 and 9). The patient was supplemented with a replacement dose of T4 the next day. The postoperative period was uneventful. The histopathological report was a colloid goiter. The patient had an uneventful outcome and was discharged on the 7th postoperative day.

Fig. 8: Gross picture of the specimen

Fig. 9: Weight of the specimen

Though surgery is the mainstay modality in managing such huge goiters, other nonsurgical options are tried for those who refuse surgery, unfit for surgery, elderly, patients with comorbid conditions and patients in special occupations (speakers, singers, and teachers).9 The nonsurgical modalities advocated being radioactive I (RAI) therapy alone or combined with recombinant human TSH, laser ablation therapy or percutaneous ethanol injection treatment (PEIT), levothyroxine with I, and thyroid artery embolization (TAE).

Radio I Therapy

It is widely used to reduce goiter size (40–60% reduction volume within 2 years of treatment).10 A dose of 30 mCu of I-131 is used.10 Recombinant human TSH is administered to enhance RAI uptake in euthyroid goiter.11 RAI is also combined with neodymium-doped yttrium aluminum garnet laser ablation and ultrasonography-guided percutaneous ethanol injection for faster goiter volume reduction, symptom relief, and reduced RAI activity needed to be administered.12 PEIT is now recommended for cystic lesions. The problems with this modality are transient thyroiditis, overt/subclinical hypothyroidism, secondary thyrotoxicosis, and radiation-induced cancers.10

Levothyroxine with I

It helps to partially suppress serum TSH levels. It reduces thyroid nodule volume by 17.3 % in 1 year.13 The disadvantages are iatrogenic subclinical hyperthyroidism, osteoporosis, poor efficacy and the necessity of lifelong suppression.10

Thyroid Artery Embolization (TAE)

It is done via a catheter introduced through the femoral artery to the vessels feeding the nodule of the thyroid and embolized with 150–500 µm sized polyvinyl alcohol particles. TAE reduces the volume of dominant/solitary nodules with a mean volume reduction of 69%.14 The problems with this approach are transient hyperthyroidism and the risk of stroke.

CONCLUSION

Surgical modality is offered to those with pressure symptoms (dysphagia/dyspnea), suspected malignancy, prevention of complications due to progressive enlargement causing tracheal narrowing or substernal extension and aesthetic reasons.10 Another advantage of surgical excision is the availability of removed tissue for histopathological examination. Though nonsurgical options mentioned above are used in patients who refuse surgery or are unfit for surgery, the definitive management of goiter is surgery, as it removes the disease in its entirety.

ACKNOWLEDGMENTS

The authors are grateful to the following departments/persons in managing this case:

  1. Department of Medical Gastroenterology, Government Tirunelveli Medical College, Tirunelveli for management of postcricoid web

  2. Department of General Medicine, ESIC Hospital Tirunelveli for management of anemia

  3. Dr K. Swaminathan, SSS Pathology Lab, Tirunelveli for histopathological examination and mounting the specimen for museum purpose.

  4. Dr Ajmal N & Dr Krishnasaranya T, Junior residents of ENT and Surgical Oncology respectively for their help in managing this case.

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