Surgical Management of Giant Bilateral Multinodular goiter with Significant Tracheal and Esophageal Outline distortion; A case report

Background Giant goitre is a rare occurrence and is defined by an enlargement of the thyroid gland of at least 10 g/kg body weight or goiter weighing more than 500 grams or a thyroid tumour larger than 10 cm in diameter. Case presentation A 65 years old female patient who presented with anterior neck swelling with progressive size increment of about 30 years duration. She developed hot intolerance, palpitation and slight voice change for about 3 years. She has no remarkable medical, surgical history. On examination, she was tachycardic and had about 32*22cm very huge anterior neck swelling with visible multiple nodules grown more anterior to the sternum. On investigation, she had low TSH and high free T3 levels. Neck ultrasound shown multinodular thyroid enlargement with cystic and calcified components. Fine needle aspiration cytology was suggestive of benign colloid goiter. Lateral neck x ray shown significant anteriorly pulled trachea. She was put on antithyroid medication for about 3 years until the TFT was corrected and surgery was decided. Intraoperatively, there was about 34*22*7cm sized well encapsulated multinodular thyroid mass with anteriorly displaced trachea, esophagus, both recurrent laryngeal nerves and parthyroid glands. We did total thyroidectomy, preserved both recurrent laryngeal nerves and parathyroid glands. The mass weighed about 2350 grams , sent for histopathology later suggestive of benign colloid goiter. Clinical discussion Despite technical challenges, surgery continues to be the best option particularly in experienced hands due to its distinct advantage of immediate effect and complete resolution of compressive symptoms. The difficulty for this case was the anteriorly curved trachea and esophagus together with the recurrent nerves and parathyroid glands. Conclusion Thyroidectomy for giant goiters needs patience to preserve important structures with the assumption that a tired surgical team can have relief with rest but for the purpose of shortening surgery time, injuring recurrent laryngeal nerves or parathyroid glands do have lifelong sequela for the patient which never shouldn’t be the choice.