Thyroid Nodul “Colloid Goiter” With Unilateral Thyroidectomy
THYROID NODUL “COLLOID GOITER” WITH UNILATERAL THYROIDECTOMY
Ashri Yudhistira, Farhat, Rizalina A Asnir, Suriyanti Otorhinolaryngology Head and Neck Department
Medical Faculty, University of Sumatera Utara
Introduction Lumps in the thyroid gland is a symptom that is often found in the thyroid gland
abnormalities, clinically recognizable, and most patients come to the clinic with complaints of a lump in the front of the neck. Basically enlargement of the thyroid gland can be caused by various diseases that do not require surgery. Enlargement of the thyroid gland is generally known as a goiter. Surgical treatment is mainly done in thyroid cancer, may also be indicated on a benign enlargement of the thyroid gland when it puts pressure on the trachea, esophagus, with shortness of breath, a sense of choking and swallowing disorders (Pasaribu, 2006).
Goiter is an enlargement of thyroid gland caused by compensatory hyperplasia & hypertrophy of the follicular epithelium which occurs sporadically and a usually of unknown etiology. Nodular goiter presents rarely before middle age and female preponderance is established. It is a clinical entity characterized by subsequent growth, structural or functional transformation of one or more areas within the normal thyroid tissue. Multi-nodular goiter is benign, whereas solitary nodules may be malignant. So in patients presenting with a solitary nodule, malignancy must be ruled out. In all patients with solitary nodule it is important to measure serum T3, T4, and TSH, though most useful is fine needle aspiration of the nodule. If a colloid goiter is small, and is causing no obvious symptoms, surgery is not really necessary, and the indications for its removal are only cosmetic. If there is dyspnoea or dysphagia, or the gland is large, subtotal thyroidectomy is indicated, but is seldom urgent. (Sharma, 2011)
Universitas Sumatera Utara
Case Presentation A 22-year-old female, was admitted to Adam Malik General Hospital on Mei 15th
2012 with chief complaint visible lump of the anterior leftneck region for the last 5 years presented, grew slowly, painless and lump part moves upward when the patient swallows. She also complaint neck discomfort and worried if the lump get bigger. There was no history of dysphagia, dyspnoea, hoarseness and loss of weight. She didn’t have history of head and neck irradiation exposure.
On physical examination vital sign was normal. ENT routine examination, we found ears were normal, nose were normal, the patient presented with single, solid, well-defined, nontender mass with size 4 x 4 x 3 approximately of the anterior left neck region (Fig. 1 and 2).
Previous Fine Needle Aspiration Biopsy (FNAB) revealed colloid goiter with hyperplasia epitel folikuler. Laboratory finding T3 : 1,45, T4 : 9,17, TSH : 1,650. Radiologically, cervical plain rontgen revealed there was no abnormality.
Based on this diagnosis, unilateral thyroidectomy was designed to gain access to the tumor under general anesthesia. After desinfection with povidone iodine and alcohol 70%, pehacain injection allowed and horizontal incision of 5 cm allowed at thyroid nodule, incision deepened and widened, muscle released from tumor mass, blood vessel ligated, tumor mass clamped and be cut, after that control the bleeding and rinsed with NaCl. Drain installed to control bleeding, surgical wound sutured starting from fascia, subcutis and cutis. The surgical specimen was of a size of 4 x 4 x 3 cm. Macroscopically, the tumor appeared to be capsulated. After the surgery, ceftriaxone 1 g/ 12 hours, ketorolac 30 mg/ 8 hours, tranexamic acid 500mg/ 12 hours and dexamethasone 5mg/ 8 hours intravenously. The patient was discharged after five days. Postoperative healing was uneventful with a satisfactory cosmetic outcome.
Universitas Sumatera Utara
Figure 1& 2. Mass of the left anterior neck region.
Figure 3. Pehacain injection
Figure 4. Horizontal incision
Figure 5. Blood vessel ligated
Figure 6. Tumor mass clamped
Universitas Sumatera Utara
Figure 7. Tumor mass
. Figure 8. Rinse with NaCl
Figure 9. Wound suture
Figure 10. Post operative
Discussion
Thyroid nodules are the most common condition presenting to the endocrine surgeon and may be a feature of many thyroid disease processes. Most of such lesions are benign, but the clinical problem is that of identifying the malignant lesion requiring surgery and distinguishing it from the benign nodule, which can often be managed conservatively. Management has evolved from surgical removal of all solitary nodules to a selective approach based on clinical, noninvasive cytologic assessment (fine-needle aspiration, or FNA) to obtain a precise diagnosis. Palpable thyroid nodules may be detected in 0,8- 1,5% of men and 5,3- 6,4% of women. Most of these nodules are benign colloid nodules composed of irregularly enlarged follicles containing abundant colloid. Causes of benign solitary nodules are thyroid adenomas, cysts, thyroiditis or it may be the largest nodule of a small, clinically unrecognized multinodular goiter (Wong et al 2000, Holzheimer 2001)
Universitas Sumatera Utara
A clinically solitary thyroid nodule is a discrete swelling within an otherwise palpably normal thyroid gland. With time, solitary thyroid nodules may enlarge, shrink, or even disappear spontaneously, but most do not change appreciably. Most of these nodules are benign colloid nodules composed of irregularly enlarged follicles containing abundant colloid. Most are actually the largest of multiple colloid nodules in small, clinically unrecognized multinodular goiters. Other causes of benign solitary nodules are thyroid adenomas, cysts, and thyroiditis. Approximately 5 percent of all solitary thyroid nodules are thyroid carcinomas (Wood et al 1998).
Fine-needle aspiration (FNA) is the main modality used today to investigate thyroid nodules. Its high accuracy, low morbidity, and cost-effectiveness make it an important tool in determining the need for surgery or observation (Bahar 2003, Myer 2009 ). In this case we found colloid goiter with hyperplasia epitel folikel.
Given the imprecision of palpation, ultrasonography is critical for evaluating changes in nodule or goiter volume in studies of therapy, but it is not indicated for routine clinical management. In these cases, ultrasonographic guidance didnot used.
The main indications for treatment of a euthyroid patient with a benign thyroid nodule that is not hyperfunctioning are compression of the trachea or esophagus, growth of the nodule, and recurrence of a cystic nodule after aspiration. Other indications for treatment are neck discomfort, cosmetic concern, and the patient's anxiety about the nodule. The main therapeutic options are surgery and thyroxine treatment (wood, 2003). In this case patient felt neck discomfort and anxiety about the nodule, so we managed the nodule by unilateral thyroidectomy.
The surgical treatment may be either excision of the nodule or unilateral thyroid lobectomy. The decision to operate or not may also depend on the reliability of diagnosis, the stability of the size of the nodule, the risk of subsequent dysfunction and the presence of other medical diseases. Solitary nodules may disappear in 38% of all cases. A thyroid nodule wich is larger than 3 cm, cystic/solid or large and cystic/solid may have a higher probability of malignancy. Unilateral thyroid lobectomy is the preferred therapy for patients with benign solitary nodules (Holzheimer, 2001)
Universitas Sumatera Utara
Conclusion Fine-needle aspiration biopsy should be the first test performed in a euthyroid patient
with a solitary thyroid nodule. Indications for treatment are : Compression of the trachea or esophagus , venous-outflow obstruction, growth of the goiter, neck discomfort and cosmetic issues.
We reported a case of colloidal goiter that managed with unilateral thyroidectomy in a 22- year- old female and resulted in favorable out come.
References
Bahar G, Braslavsky D, Shpitzer T, Feinmesser R, Avidan S, The cytological and clinical value of the thyroid “ follicular lesion” , American journal of otolaryngology, 2003 Christiansen, Leighton L, Thyroidectomy and thyroid lobectomy, IOWA head and neck protocol, 2014 Frilling A, Liu C, Weber F, Benign multinodular goiter, scandinavian journal of surgery 93: 278-281, 2004 Holzheimer RG, Mannick JA, Benign nodular thyroid disease, surgical treatment: evidencebased and problem-oriented; 2001 Myers E N, Thyroidectomy, Myers surgery, 15- 9 -2009 Pasaribu E T, Pembedahan pada kelenjar tiroid, majalah kedokteran nusantara volume 39, no 3, september 2006 Sharma B, A case of colloidal nodular goiter, indian journal of research in homoeopathy, vol 5, no 2, april- june,2011 Wong C, Wheeler M, Thyroid Nodules : Rational Management, World journal of Surgery, 24, 934-941, 2000 Wood A, Hermus AR,Treatment of benign nodular thyroid disease, the new england journal of medicine, 1438-1447, 1998
Universitas Sumatera Utara
Ashri Yudhistira, Farhat, Rizalina A Asnir, Suriyanti Otorhinolaryngology Head and Neck Department
Medical Faculty, University of Sumatera Utara
Introduction Lumps in the thyroid gland is a symptom that is often found in the thyroid gland
abnormalities, clinically recognizable, and most patients come to the clinic with complaints of a lump in the front of the neck. Basically enlargement of the thyroid gland can be caused by various diseases that do not require surgery. Enlargement of the thyroid gland is generally known as a goiter. Surgical treatment is mainly done in thyroid cancer, may also be indicated on a benign enlargement of the thyroid gland when it puts pressure on the trachea, esophagus, with shortness of breath, a sense of choking and swallowing disorders (Pasaribu, 2006).
Goiter is an enlargement of thyroid gland caused by compensatory hyperplasia & hypertrophy of the follicular epithelium which occurs sporadically and a usually of unknown etiology. Nodular goiter presents rarely before middle age and female preponderance is established. It is a clinical entity characterized by subsequent growth, structural or functional transformation of one or more areas within the normal thyroid tissue. Multi-nodular goiter is benign, whereas solitary nodules may be malignant. So in patients presenting with a solitary nodule, malignancy must be ruled out. In all patients with solitary nodule it is important to measure serum T3, T4, and TSH, though most useful is fine needle aspiration of the nodule. If a colloid goiter is small, and is causing no obvious symptoms, surgery is not really necessary, and the indications for its removal are only cosmetic. If there is dyspnoea or dysphagia, or the gland is large, subtotal thyroidectomy is indicated, but is seldom urgent. (Sharma, 2011)
Universitas Sumatera Utara
Case Presentation A 22-year-old female, was admitted to Adam Malik General Hospital on Mei 15th
2012 with chief complaint visible lump of the anterior leftneck region for the last 5 years presented, grew slowly, painless and lump part moves upward when the patient swallows. She also complaint neck discomfort and worried if the lump get bigger. There was no history of dysphagia, dyspnoea, hoarseness and loss of weight. She didn’t have history of head and neck irradiation exposure.
On physical examination vital sign was normal. ENT routine examination, we found ears were normal, nose were normal, the patient presented with single, solid, well-defined, nontender mass with size 4 x 4 x 3 approximately of the anterior left neck region (Fig. 1 and 2).
Previous Fine Needle Aspiration Biopsy (FNAB) revealed colloid goiter with hyperplasia epitel folikuler. Laboratory finding T3 : 1,45, T4 : 9,17, TSH : 1,650. Radiologically, cervical plain rontgen revealed there was no abnormality.
Based on this diagnosis, unilateral thyroidectomy was designed to gain access to the tumor under general anesthesia. After desinfection with povidone iodine and alcohol 70%, pehacain injection allowed and horizontal incision of 5 cm allowed at thyroid nodule, incision deepened and widened, muscle released from tumor mass, blood vessel ligated, tumor mass clamped and be cut, after that control the bleeding and rinsed with NaCl. Drain installed to control bleeding, surgical wound sutured starting from fascia, subcutis and cutis. The surgical specimen was of a size of 4 x 4 x 3 cm. Macroscopically, the tumor appeared to be capsulated. After the surgery, ceftriaxone 1 g/ 12 hours, ketorolac 30 mg/ 8 hours, tranexamic acid 500mg/ 12 hours and dexamethasone 5mg/ 8 hours intravenously. The patient was discharged after five days. Postoperative healing was uneventful with a satisfactory cosmetic outcome.
Universitas Sumatera Utara
Figure 1& 2. Mass of the left anterior neck region.
Figure 3. Pehacain injection
Figure 4. Horizontal incision
Figure 5. Blood vessel ligated
Figure 6. Tumor mass clamped
Universitas Sumatera Utara
Figure 7. Tumor mass
. Figure 8. Rinse with NaCl
Figure 9. Wound suture
Figure 10. Post operative
Discussion
Thyroid nodules are the most common condition presenting to the endocrine surgeon and may be a feature of many thyroid disease processes. Most of such lesions are benign, but the clinical problem is that of identifying the malignant lesion requiring surgery and distinguishing it from the benign nodule, which can often be managed conservatively. Management has evolved from surgical removal of all solitary nodules to a selective approach based on clinical, noninvasive cytologic assessment (fine-needle aspiration, or FNA) to obtain a precise diagnosis. Palpable thyroid nodules may be detected in 0,8- 1,5% of men and 5,3- 6,4% of women. Most of these nodules are benign colloid nodules composed of irregularly enlarged follicles containing abundant colloid. Causes of benign solitary nodules are thyroid adenomas, cysts, thyroiditis or it may be the largest nodule of a small, clinically unrecognized multinodular goiter (Wong et al 2000, Holzheimer 2001)
Universitas Sumatera Utara
A clinically solitary thyroid nodule is a discrete swelling within an otherwise palpably normal thyroid gland. With time, solitary thyroid nodules may enlarge, shrink, or even disappear spontaneously, but most do not change appreciably. Most of these nodules are benign colloid nodules composed of irregularly enlarged follicles containing abundant colloid. Most are actually the largest of multiple colloid nodules in small, clinically unrecognized multinodular goiters. Other causes of benign solitary nodules are thyroid adenomas, cysts, and thyroiditis. Approximately 5 percent of all solitary thyroid nodules are thyroid carcinomas (Wood et al 1998).
Fine-needle aspiration (FNA) is the main modality used today to investigate thyroid nodules. Its high accuracy, low morbidity, and cost-effectiveness make it an important tool in determining the need for surgery or observation (Bahar 2003, Myer 2009 ). In this case we found colloid goiter with hyperplasia epitel folikel.
Given the imprecision of palpation, ultrasonography is critical for evaluating changes in nodule or goiter volume in studies of therapy, but it is not indicated for routine clinical management. In these cases, ultrasonographic guidance didnot used.
The main indications for treatment of a euthyroid patient with a benign thyroid nodule that is not hyperfunctioning are compression of the trachea or esophagus, growth of the nodule, and recurrence of a cystic nodule after aspiration. Other indications for treatment are neck discomfort, cosmetic concern, and the patient's anxiety about the nodule. The main therapeutic options are surgery and thyroxine treatment (wood, 2003). In this case patient felt neck discomfort and anxiety about the nodule, so we managed the nodule by unilateral thyroidectomy.
The surgical treatment may be either excision of the nodule or unilateral thyroid lobectomy. The decision to operate or not may also depend on the reliability of diagnosis, the stability of the size of the nodule, the risk of subsequent dysfunction and the presence of other medical diseases. Solitary nodules may disappear in 38% of all cases. A thyroid nodule wich is larger than 3 cm, cystic/solid or large and cystic/solid may have a higher probability of malignancy. Unilateral thyroid lobectomy is the preferred therapy for patients with benign solitary nodules (Holzheimer, 2001)
Universitas Sumatera Utara
Conclusion Fine-needle aspiration biopsy should be the first test performed in a euthyroid patient
with a solitary thyroid nodule. Indications for treatment are : Compression of the trachea or esophagus , venous-outflow obstruction, growth of the goiter, neck discomfort and cosmetic issues.
We reported a case of colloidal goiter that managed with unilateral thyroidectomy in a 22- year- old female and resulted in favorable out come.
References
Bahar G, Braslavsky D, Shpitzer T, Feinmesser R, Avidan S, The cytological and clinical value of the thyroid “ follicular lesion” , American journal of otolaryngology, 2003 Christiansen, Leighton L, Thyroidectomy and thyroid lobectomy, IOWA head and neck protocol, 2014 Frilling A, Liu C, Weber F, Benign multinodular goiter, scandinavian journal of surgery 93: 278-281, 2004 Holzheimer RG, Mannick JA, Benign nodular thyroid disease, surgical treatment: evidencebased and problem-oriented; 2001 Myers E N, Thyroidectomy, Myers surgery, 15- 9 -2009 Pasaribu E T, Pembedahan pada kelenjar tiroid, majalah kedokteran nusantara volume 39, no 3, september 2006 Sharma B, A case of colloidal nodular goiter, indian journal of research in homoeopathy, vol 5, no 2, april- june,2011 Wong C, Wheeler M, Thyroid Nodules : Rational Management, World journal of Surgery, 24, 934-941, 2000 Wood A, Hermus AR,Treatment of benign nodular thyroid disease, the new england journal of medicine, 1438-1447, 1998
Universitas Sumatera Utara