Multi nodular goiter is a relatively common thyroid disorder with a marked female preponderance. Most of these goiters weigh less than 100 grams. Glands weighing more than 500 grams are extremely unusual and often result as a consequence of ignorance, neglect, lack of inadequate medical facility, fear of undergoing surgery or due to an unusually rapid growth as in malignancy. These patients pose a specific surgical challenge and need to be managed by experienced surgeons.
A 46 year old man presented with a massively enlarged goiter since 3 years. There was a sudden increase in size since last 6 months. He had a recent history of sudden onset of dyspnea. On clinical examination the mass measured 18x 16cm, involving most of neck until the anterior border of trapezius. The lower borders could not be felt. The CBC & Thyroid function tests was normal. A CT Scan revealed a massive goiter, compressing the trachea with retro sternal extension.
After an informed consent, the patient underwent total thyroidectomy. Neck was explored with an incision up till the sternomastoid muscle. Strap muscles were divided for adequate exposure and there was significant compression of I.J.V and carotid vessels and distortion and displacement of these structures. The superior pedicle multiple dilated middle and inferior thyroid veins and branches of inferior thyroid artery were carefully ligated on both sides. The recurrent laryngeal & parathyroid were identified & preserved on both sides. Retro sternal extension of gland was delivered by gentle finger dissection and upward traction. Tracheal cartilage appeared healthy. There was no post-operative complication and patient was discharged on third post op day. Histopathology was reported as multinodular goiter, the total weight of gland being 550gms.
Thyroidectomy for massively enlarged goiter could be technically challenging particularly when they weigh more than 500 grams. The specific problems associated with them are difficulty in securing airway, adequate exposure, blood loss, and potential risk of injury to the recurrent laryngeal nerve, esophagus and the parathyroid gland due to distorted and displaced anatomy. Moreover there is an increased possible association of tracheomalacia, tracheal compression, retro sternal extension and skin complications due to ulceration or infiltration by the massively enlarged goiter. The surgical approach to such cases requires careful preoperative evaluation and planning.
Intubation of these patients could be demanding due to gross tracheal deviation, compression or tracheomalacia and should be anticipated by the anesthetists in the pre anesthetic assessment.
Tracheomalacia is an uncommon complication in a patient undergoing thyroidectomy and occurs in 0.1 to 0.5%. However in patients with massively enlarged goiter the risk is relatively higher. The major concern is that it may cause life threatening post-operative airway obstruction with the recorded mortality of 44%. Its mechanical effect usually results from
compression by the surrounding goiter leading to softening of the tracheal cartilage. The trachea may collapse immediately following extubation or as late as 48 hours into the postoperative period. In patients at risk of developing upper airway obstruction following thyroidectomy, the choice lies between prophylactic endotracheal intubation and tracheostomy.
In spite of the technical challenge related to the airway, and thyroidectomy, surgery continues to be the best option in experienced hands due to its distinct advantage of its immediate effect and complete resolution of compressive symptoms.
Specialist General Surgeon
Aster Hospital, Mankhool