84126546 case write up harmeet multinodular goitre

8/12/2019 84126546 Case Write Up Harmeet Multinodular Goitre

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CASE WRITE UP

Department of Surgery

Cyberjaya University College of Mei!al S!ien!es

MU"TI#$DU"AR %$ITRE

#ame& 'armeet (aur a)p Daleep Sing*

Matri! #o+& ,-,./0123

4ear)%roup& 4ear 2)%roup 3

Supervisor& Mr A*me A5il Aam

Core Component %iven Mar6s

'istory

P*ysi!al E7amination

Investigation

Provisional Diagnosis)Differential Diagnosis

Dis!ussion& Ientify problems8 management an

progress of patient

Referen!es

0+ 'IST$R4

0+0 Demograp*i! Data

1


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Patient Name: Maslina Bt Ahmad

Age: 66 years old

Sex: Female

Origin: Batu Pahat, Johor

Date of admission: !thDe"em#er $%%

Date of &ler'ing: ($th De"em#er $%%

Pla"e of "ler'ing: Putra)aya *os+ital

0+1 'istory of Presenting Illness

&hief "om+lain: Madam Maslina +resented to the mergen"y De+artment follo-ing an

e+isode of shortness of #reath -hi"h lasted a#out half an hour on ! thDe"em#er $%%

Madam Maslina.s history dates #a"' to year $$$ -here she first noti"ed a ne"' s-elling

on #oth sides of her ne"'/ 0t -as relati1ely small si2ed, -ith the right side #eing #igger than the

left side/ 0t -as not +ainful and felt li'e multi+le, small, seed li'e s-ellings 3in her -ords4 on her

ne"'/ 0t -as soft and mo#ile too/ 5here -as no dis"harge or ul"ers at the site of s-elling and

neither -as it it"hy or asso"iated -ith any e"2ema/ She noti"ed the s-elling a fe- months after

she had deli1ered her th"hild/ At that time, she also had lethargy and had lost -eight, a#out !'g

in the s+an of ( months/ She also had heada"he on and off/ *er food inta'e -as the same though,

-ith no in"rease or de"rease in a++etite/ She did not eat mu"h seafood either/ She had no heat or

"old intoleran"e, diffi"ulty in #reathing or dys+hagia at that time either/ She did not noti"e any

o1ert s-eating or tremors as -ell/ 5here -as also no "hange in 1oi"e, diarrhea, +al+itations or

s-elling any-here else on her #ody/ *er systemi" re1ie- -as unremar'a#le at that time/

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3/29

Due to her ne"' s-elling, she -ent to Batu Pahat hos+ital at that time 3year $$$4 to see

the do"tor and -as told that she most +ro#a#ly had a +ro#lem -ith her thyroid gland #ut nothing

-as done and no medi"ations -ere gi1en either/ 5he s-elling gradually in"reased in si2e o1er the

years #ut she did not thin' that it -as serious as she didn.t noti"e it #e"oming #igger until year

$$7 -here she -as s"heduled to do a surgery 3thyroide"tomy4 in Batu Pahat hos+ital #ut the

surgery -as +ost+oned as her thyroid hormone le1els -ere high/ *en"e she -as dis"harged -ith

medi"ations to sta#ili2e her thyroid hormone le1el and -as as'ed to "ome #a"' again after a year

and a half/ She defaulted her follo- u+ though/

No-, in De"em#er $%, she +resented to the D of Batu Pahat hos+ital -ith SOB -hi"h

o""urred at rest and lasted till she got to the D, -hi"h -as a#out half an hour/ 0t had a sudden

onset and -as asso"iated -ith syn"o+y -hi"h o""urred -hile she -as on the -ay to the hos+ital/

5he syn"o+y lasted a#out a fe- minutes though and she gained "ons"iousness in the D/ She

e1en had fe1er %8 days +rior to admission -hi"h -as intermittent in nature/ She did not ta'e any

medi"ations to relie1e her fe1er though/ She had no +rior e+isodes of dys+nea, ortho+nea or

+aroxysmal no"turnal dys+nea #efore this/ She did not ha1e any leg s-elling or "hest +ain and

did not ha1e dys+hagia +rior to admission either/ *er ne"' s-elling -as no- mu"h #igger in

si2e, a#out %!"m in length/ She had lost more -eight o1er the years, gradually though #ut did not

remem#er the amount/ Systemi" re1ie- -as unremar'a#le/

0n Batu Pahat hos+ital, they too' a long time to intu#ate her as it -as diffi"ult to do so

and referred her to Putra)aya *os+ital on that day itself/

0+2 Past Mei!al 'istory

She -as diagnosed to ha1e hy+ertension in $$7 during her routine "he"'u+/ She does

not ha1e any other "hroni" illnesses though/ She had not gone for any surgery #efore this either/

0+9 :amily 'istory

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*er +arents ha1e +assed a-ay/ *er father had asthma -hile he -as ali1e -hile her

mother had hy+erthyroidism, hy+ertension and dia#etes mellitus/ She has si#lings -hose ages

range from $8!$ something years old/ *er #rother has hy+ertension and dia#etes mellitus -hile

her sister has rheumatoid arthritis and dia#etes mellitus/ *er other younger sister has

hy+erthyroidism too/ She is married -ith ! "hildren -hose ages range from !8$ years old/ 5hey

are all healthy/ *en"e, the ones -ith similar +ro#lems as her are her younger sister and mother/

0+3 Drug 'istory

She used to ta'e medi"ations #ut only from year $$7/ She ta'es a medi"ation to redu"e

her thyroid hormone le1els and is on anti8hy+ertensi1es/ She does not remem#er the name of her

drugs though/ She is not "om+liant to her anti8hy+ertensi1es though as she ta'es them -hen she

has heada"hes only/ She is not allergi" to any drugs and has not ta'en any traditional medi"ine

+re1iously/

0+; So!ial 'istory

She does not smo'e nor "onsumes al"ohol/ She li1es -ith her "hildren and is generally

-ell loo'ed after/ She is married -ith ! "hildren and her hus#and is still -or'ing as a "ontra"tor/

She is a "aterer and has a food #usiness of her o-n/

1+ P'4SICA" E


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1+0 %eneral Inspe!tion

Post8o+

On general ins+e"tion, she -as "ons"ious and -as sitting u+ "omforta#ly on her #ed and

-as using a nasal +rong/ She -as not in res+iratory distress and -as alert/ She -as orientated to

time and s+a"e/ She also had a #ranula inserted on the dorsal +art of her hand and she -as on

&BD/ *er +alms -ere slightly moist/ 5here -as no "lu##ing or any other nail "hanges/ 5here

-as slight tremor though/ She -as not +ale or )aundi"ed and there -as no "entral or +eri+heral

"yanosis/ She -as slightly dehydrated though/ *er fa"e is not edematous/

1+1 =ital signs

9+on admission:

BP: %!;7 mm;*g

*eart rate: %$(;min


6/29

BP: %($;!

*eart rate: ;min


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Post o+erati1ely, she has a fresh s"ar on her ne"' -ith 1isi#le stit"hes and no dressing/ 0t

is a hori2ontal s"ar measuring a#out %$"m/ 5here is a "atheter inserted at the o+erati1e area to

drain #lood from it/ *er 1oi"e is no- hoarse and she "an #arely -his+er out -ords/

1+9 Systemi! revie5&

yes: slight lid retra"tion and infre?uent #lin'ing +re o+erati1ely, no exo+thalmos and she "an

"on1erge her eyes, no +tosis

&ardio1as"ular system: unremar'a#le


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%/ 5hyroid "ar"inoma

/ @ra1es. disease

(/ ym+hadeno+athy

9+ I#=ESTI%ATI$#S

9+0 Pre/$p >13t* De!ember 1,00?

%/ Full Blood &ount

Component =alues #ormal Range

5otal hite Blood &ells 02+. 38%%4 x %$7"ells


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osino+hils $ 3$/$8$/4 x %$7;

Baso+hils $ (0.1.0.1) x %$7;

/


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!/ Minerals

Component =alue #ormal Range

Phos+hate %/(( 3$/8%/!4 mmol;l

Magnesium 0+,; 3$/E!8%/$4 mmol;l

&al"ium 1+,- 3/%8/64 mmol;l

6/ &t s"an = retrosternal ex+ansion to le1el 5%85

9+1 Post op >1.t* De!ember 1,00?

%/ Full Blood &ount

Component =alues #ormal Range

5otal hite Blood &ells 03+@ 38%%4 x %$7"ells


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/


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6/ i+id +rofile

Component =alue #ormal Range

*D %/( 3%/$8/4 mmol;l

D /6 3/$8(/4 mmol;l

5otal "holesterol /E 3(/$86/!4 mmol;l

5@ %/E 3$/68%/E4 mmol;l

E/ Bio+sy done of goiter done: results un'no-n

3+ DISCUSSI$#

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5his +atient has a ne"' s-elling/ 5here are many "auses to ne"' s-elling su"h as:

Ba"terial

Ba"terial+haryngitis

Peritonsillar a#s"ess

Stre+ throat

5onsillitis

5u#er"ulosis

&an"er

*odg'inIs disease

eu'emia

Non8*odg'inIs lym+homa

5hyroid

5hyroid "ar"inoma

@oitre

@ra1esI disease

5hyroglossal du"t "ysts

5hyroiditis

iral

13
http://www.nlm.nih.gov/medlineplus/ency/article/000655.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000986.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000639.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000580.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001299.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000581.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000358.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000986.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000639.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000580.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001299.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000581.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000358.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000655.htm


14/29

A0DS

*er+es infe"tions

0nfe"tious mononu"leosis


15/29

+oly+hagia though, -hi"h is normally a sym+tom seen -ith hy+erthyroidism/ She does not eat

any seafood -hi"h means that her iodine le1el "ould #e lo- and this "an "ause goiter too/ She

had no heat intoleran"e either -hi"h indi"ates that her BM< is not too high/ She also did not

ha1e dys+hagia -hi"h is normally the su++orting sym+tom for retrosternal ex+ansion, ho-e1er

the SOB is ?uite indi"ati1e of that already/ *er SOB had also "aused syn"o+y/

SOB has many "auses related to the heart and lungs #ut 0 thin' that it is highly unli'ely as

she has no history of ortho+nea, dys+nea or PND #efore and neither does she ha1e any "hest +ain

or +edal edema/ She also does not ha1e any "ough -hi"h again rules out other "auses of SOB/

*en"e, gi1en her sym+toms -hi"h are more that of hy+erthyroidism, 0 sus+e"t that this is a "ase

of hy+erthyroidism -ith retrosternal ex+ansion/ She has a family history of hy+erthyroidism as

her mother and sister has it too/ She also ta'es anti8hy+ertensi1e drugs and anti thyroid drugs

-hi"h -ere #oth gi1en to her in year $$7 #ut she -as not "om+liant to either of them/ *en"e,

her ne"' s-elling in"reased in si2e and has "ause tra"heal "om+ression no-/ 9+on admission her

BP -as high, she -as ta"hy"ardi" and ta"hy+ni"/ 5he ta"hy"ardia and hy+ertension -as +ro#a#ly

due to her hy+erthyroidism -hile the ta"hy+nea -as "aused #y the tra"heal "om+ression #y the

thyroid gland/ 9+on examining her ne"', 0 noted that she had a large s-elling -hi"h -as #igger

on the right side rather than the left and had a nodular surfa"e/ 0t -as rather firm #ut -as mo#ile/

*er 1eins -ere also distended at the sides of the s-elling/ 5his "ould #e due to +ressure of the

internal )ugular 1eins in the thora"i" inlet #y the enlarged thyroid gland/ 5he s-elling mo1ed

-ith deglutition -hi"h is indi"ati1e that it -as the thyroid gland as the thyroid gland is en"losed

in the +retra"heal fas"ia -hi"h is fixed to the thyroid "artilage so -hen the su+erior "onstri"tor of

larynx +ulls the thyroid "artilage u+ during deglutition, the gland also mo1ed u+ and do-n/ Other

s-elling that mo1es -ith deglutition are thyroglossal "yst, +retra"heal lym+h nodes, su#hyoid

#ursa, and extrinsi" "a of larynx/

5he s-elling -as not tender and the tra"heal rings -ere not +al+a#le/ 5his is indi"ati1e of

a retrosternal ex+ansion/ 5o "onfirm it, 0 "ould ha1e "om+ressed her lateral lo#es -hi"h -ould

ha1e "aused stridor, indi"ating narro-ing of tra"hea due to the +resen"e of a s"a##ard tra"hea

due to "om+ression #y an enlarged thyroid gland #ut 0 didn.t do so as she -as already in

res+iratory distress/ On +er"ussion o1er the manu#rium sternum, dullness -as heard -hi"h on"e

again indi"ates retrosternal ex+ansion due to an enlarged thyroid gland/ She had the

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hy+erthyroidism eye signs of lid retra"tion and infre?uent #lin'ing #ut she did not ha1e

exo+thalmos -hi"h indi"ates that she most +ro#a#ly does not ha1e @ra1es. disease/ *er other

systems -ere unremar'a#le -hi"h ruled out other reason of SOB su"h as +leural effusion and

there -as no lym+h nodes enlargement -hen 0 +al+ated her "er1i"al lym+h nodes -hi"h

indi"ates that the "ause of her s-elling is not due to lym+hadeno+athy either/ She also did not

ha1e +reti#ial myxedema -hi"h on"e again indi"ates that she "an.t #e ha1ing @ra1es. disease/

5hus my +ro1isional diagnosis is multinodular goiter as she had some sym+toms of

hy+erthyroidism su"h as a ne"' s-elling -hi"h -as gradually in"reasing in si2e for the +ast %%

years, lethargy, -eight loss, and heada"he and some signs too su"h as tremors, moist hands, lid

retra"tion and infre?uent #lin'ing/ 5he surfa"e of the ne"' s-elling -as also nodular, mo#ile and

+ainless -hi"h again su++orts the diagnosis/ She also had SOB and her tra"heal rings "ould not

#e +al+ated and her manu#rium sternum -as dull to +er"ussion -hi"h indi"ates a retrosternal

ex+ansion of the goiter/ All the other differentials -ere already ruled out a#o1e/

5his is "onfirmed #y the in1estigations es+e"ially the thyroid fun"tion test -hi"h sho-ed

that her 5S* le1els -ere lo- -hile her 5 and 5( le1els -ere normal -hi"h is due to her anti8

thyroid drugs that she has #een on sin"e year $$7/ *er total -hite #lood "ell "ount -as also

high, +ro#a#ly due to rea"ti1e leu"o"ytosis, and her "al"ium le1els are slightly lo- -hi"h on"e

again the surgeon must ta'e note as if "are is not ta'en during the surgery and her +arathyroid

glands are remo1ed, her "al"ium le1el -ould go lo-er still -hi"h "an "ause future "om+li"ations

su"h as osteo+orosis/ *er &5 s"an also "onfirms the diagnosis as it sho-s retrosternal ex+ansion

to le1el 5%85/ No- -e shall tal' a#out the thyroid gland, the hormone it releases and

hy+erthyroidism/

5he thyroid gland "onsists of t-o lateral lo#es "onne"ted #y an isthmus/ 0t is "losely

atta"hed to the thyroid "artilage and to the u++er end of the tra"hea, and thus mo1es on

s-allo-ing 3li'e ho- hers did4/ m#ryologi"ally it originates from the #ase of the tongue anddes"ends to the middle of the ne"'/


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5hyrotro+hin8releasing hormone 35


18/29

Physiologi"al effe"ts of thyroid hormones are:

&ardio1as"ular system 8 in"reased heart rate and "ardia" out+ut/

S'eletal 8 in"reased #one turno1er and resor+tion/


19/29

Meta#olism of li+ids 8 in"reased li+olysis and "holesterol synthesis and degradation/

Sym+atheti" ner1ous tissue 8 in"reases "ate"holamine sensiti1ity and K8adrenergi"

re"e+tor num#ers in heart, s'eletal mus"le, adi+ose "ells and lym+ho"ytes/ De"reases

"ardia" L8adrenergi" re"e+tors/

*y+erthyroidism 3thyroid o1era"ti1ity, thyrotoxi"osis4 is "ommon, affe"ting +erha+s 8

!C of all females at some time and -ith a sex ratio of ! : %, most often #et-een the ages of $

and $ years/ Nearly all "ases 3 77C4 are "aused #y intrinsi" thyroid disease> a +ituitary "ause is

extremely rare/ 5he "auses of hy+erthyroidism are :

Common

@ra1esI disease 3autoimmune4

5oxi" multinodular goitre

Solitary toxi" nodule;adenoma

Un!ommon

A"ute thyroiditis

1iral 3e/g/ de uer1ainIs4

autoimmune

+ost8irradiation

+ost+artum

@estational thyrotoxi"osis 3*&@ stimulated4

Neonatal thyrotoxi"osis 3maternal thyroid anti#odies4

xogenous iodine

Drugs 8 amiodarone 5hyrotoxi"osis fa"titia 3se"ret 5"onsum+tion4

Rare

5S*8se"reting +ituitary tumours

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20/29

Metastati" differentiated thyroid "ar"inoma

*&@8+rodu"ing tumours

*y+erfun"tioning o1arian teratoma 3struma o1arii4

5he most "ommon "auses of hy+erthyroidism are @ra1es. disease and multinodular goiter

3)ust as my +atient has4/ 5he differen"es #et-een the are as #elo-:

&hara"teristi" @ra1es disease Multinodular goiter

Autoimmune anti#odies +resent A#sent

O+thalmo+athy Present -ith exo+thalmos A#sent

Preti#ial myxedema +resent A#sent

Pers+iration More ess

Age of +atient 9sually younger sin"e it is an

autoimmune disease

$ years or older

&lu##ing &an o""ur if they ha1e

5hyroid a"ro+a"hy

A#sent

5hyroid enlargement Normally diffuse sim+le

goiter, not nodular

Nodular goitre, "an #e 1ery

huge

5ra"heal "om+ression 9n"ommon ery "ommon

My +atient has a multinodular goiter/ @oitre is more "ommon in -omen than in men and

may #e either +hysiologi"al or +athologi"al/ Most "ommonly goiters are noti"ed as a "osmeti"

defe"t #y the +atient or #y friends or relati1es/ 5he ma)orities are +ainless, #ut +ain or dis"omfort

"an o""ur in a"ute 1arieties/ arge goitres "an +rodu"e dys+hagia and diffi"ulty in #reathing,

im+lying oeso+hageal or tra"heal "om+ression/ My +atient had a +ainless goiter -hi"h had

"aused tra"heal "om+ression/ 5he nature "an often #e )udged "lini"ally/ @oitres are usually

se+ara#le into diffuse and nodular ty+es, the "auses of -hi"h differ/ 5he "auses of goiter are

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21/29

Diffuse

Sim+le

Physiologi"al 3+u#erty, +regnan"y4

Autoimmune

@ra1esI disease

*ashimotoIs disease

5hyroiditis

A"ute 3de uer1ainIs thyroiditis4

0odine defi"ien"y 3endemi" goitre4

Dyshormonogenesis

@oitrogens 3e/g/ sulfonylureas4

#oular

Multinodular goitre

Solitary nodular

Fi#roti" 3


22/29

o""urred to my +atient as she had SOB/ 0t may also extend retrosternally, )ust li'e my +atient as

her tra"heal rings "ould not #e +al+ated and there -as dullness to +er"ussion of the manu#rium

sternum/ 5he "lassi"al Imultinodular goitreI is usually readily a++arent "lini"ally, #ut it should #e

noted that modern, high8resolution ultrasound fre?uently re+orts multi+le small nodules in glands

-hi"h are "lini"ally diffusely enlarged and asso"iated -ith autoimmune thyroid disease/ 5hese

nodules are also found in u+ to $C of the normal +o+ulation/

Malignan"y should #e "onsidered in any solitary nodule 8 ho-e1er, the ma)orities of su"h

nodules are "ysti" or #enign and, indeed, may sim+ly #e the largest nodule of a multinodular

goitre/ 5he diagnosti" "hallenge is to identify the small minority of malignant nodules, -hi"h

re?uire surgery, from the ma)ority of #enign nodules, -hi"h do not/ A history of ra+id

enlargement, asso"iated lym+h nodes or o""asionally +ain in su"h a situation suggests the

+ossi#ility of thyroid "ar"inoma, #ut in1estigations are +aramount/


23/29

My +atient only had goiter, -eight loss, tremors and moist +alms as she -as ta'ing anti8

thyroid drugs -hi"h "ontrolled the other sym+toms of hy+erthyroidism/

0n1estigations that should #e done if one sus+e"ts hy+erthyroidism are:

T*yroi fun!tion tests8 5S* +lus free 5or 5(

T*yroi antiboies8 to ex"lude autoimmune aetiology/

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24/29

Ultrasoun/ 9ltrasound -ith high resolution is a sensiti1e method for delineating

nodules and "an demonstrate -hether they are "ysti" or solid/ 0n addition, a multinodular

goitre may #e demonstrated -hen only a single nodule is +al+a#le/ 9nfortunately, e1en

"ysti" lesions "an #e malignant and thyroid tumours may arise -ithin a multinodular

goitre> therefore fine8needle as+iration is often re?uired and +erformed under ultrasound

"ontrol at the same time as the s"an/

C*est an t*ora!i! inlet in 1ie- of this, FNA should #e

+erformed/ 5his "an #e done in the out+atient "lini"/ &ytology in ex+ert hands "an

usually differentiate the sus+i"ious or definitely malignant nodule/

FNA redu"es the ne"essity for surgery, #ut there is a !C false8negati1e rate -hi"h must

#e #orne in mind 3and the +atient a++ro+riately "ounselled4/ &ontinued o#ser1ation is

re?uired -hen an isolated thyroid nodule is assumed to #e #enign -ithout ex"ision/

0n my +atient, they only did the thyroid fun"tion test/ 5hyroid anti#odies -ere not done

as it seemed highly unli'ely gi1en her age and the nature of her goiter/ 5hey did not ha1e to do

an ultrasound as a multinodular goiter -as already +al+a#le/ 5hey should ha1e done a "hest x8ray

to "onfirm the tra"heal "om+ression though and they should ha1e also done a FNA to rule out

malignan"y/ 5he rest of their in1estigations -ere )ustified though, su"h as FB& -as done to see

-hether there -as any infe"tion and -hether her *# and +latelet le1els are normal, gi1en that

she is s"heduled for surgery and this should #e re1ie-ed #efore sending her in to a1oid #leeding

+ro#lems/


25/29

+ainless and mo1es freely on s-allo-ing/ *ardness and irregularity, due to "al"ifi"ation, may

simulate "ar"inoma/ A +ainful nodule or the sudden a++earan"e or ra+id enlargement of a nodule

raises sus+i"ion of "ar"inoma> ho-e1er, su"h "ases are usually due to haemorrhage into a sim+le

nodule/ Differential diagnosis from autoimmune thyroiditis may #e diffi"ult and the t-o

"onditions fre?uently "oexist/ My +atient -as euthyroid, her nodules -ere +al+a#le and firm,

+ainless, nodular and mo1ed -ith s-allo-ing/ 0t -as 1ery indi"ati1e of multinodular goiter

undeed/ 5he general -or' u+ to rea"h a diagnosis is as #elo-:

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26


27/29

ong8term follo-8u+ studies of hy+erthyroidism sho- a slight in"rease in o1erall

mortality, -hi"h affe"ts all age grou+s, is not fully ex+lained and tends to o""ur in the first year

after diagnosis/ 5hereafter, the only long8term ris' of ade?uately treated hy+erthyroidism a++ears

to #e an in"reased ris' of osteo+orosis/ Patients -ith +ersistently su++ressed 5S* le1els ha1e an

in"reased li'elihood of de1elo+ing atrial fi#rillation -hi"h may +redis+ose to throm#oem#oli"

disease/

5hus, hy+erthyroidism should #e "orre"ted/ 5hree +ossi#ilities are a1aila#le: antithyroid

drugs, radioiodine and surgery/ 5hyroide"tomy should #e +erformed only in +atients -ho ha1e

+re1iously #een rendered euthyroid/ &on1entional +ra"ti"e is to sto+ the antithyroid drug %$8%

days #efore o+eration and to gi1e +otassium iodide 36$ mg three times daily4, -hi"h redu"es the

1as"ularity of the gland/ hen thyroid fun"tion is a#normal the +atient should #e renderedeuthyroid/ 0ndi"ations for surgi"al inter1ention are:

The possibility of malignancy/ A history of ra+id gro-th, +ain, "er1i"al lym+hadeno+athy,

"hange in 1oi"e or +re1ious irradiation to the ne"' are -orrying features/ A +ositi1e or

sus+i"ious FNA ma'es surgery mandatory and surgery may #e ne"essary if dou#t +ersists

e1en in the +resen"e of a negati1e FNA 3es+e"ially if the +atient is "on"erned #y the false

negati1e rate4/

Pressure symptoms on the trachea or, more rarely, oesophagus/ 5he +ossi#ility of

retrosternal extension should #e ex"luded/

Cosmetic reasons/ A large goitre is often a "onsidera#le anxiety to the +atient e1en

though fun"tionally and anatomi"ally #enign/

5he o+eration should #e +erformed only #y ex+erien"ed surgeons to redu"e the "han"e of

"om+li"ations:

arly +osto+erati1e #leeding "ausing tra"heal "om+ression and as+hyxia is a rare

emergen"y re?uiring immediate remo1al of all "li+s;sutures to allo- es"a+e of the

#lood;haematoma/

aryngeal ner1e +alsy o""urs in %C/ o"al "ord mo1ement should #e "he"'ed

+reo+erati1ely/

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5ransient hy+o"al"aemia o""urs in u+ to %$C #ut -ith +ermanent hy+o+arathyroidism in

fe-er than %C/


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84126546 case write up harmeet multinodular goitre

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