GOITRE MANAGEMENT

1. MANAGEMENT OF
SIMPLE MULTINODULAR
GOITRE
Dr. ADESIYAKAN DOTUN

2. OUTLINE
• INTRODUCTION
• HISTORY
• EPIDEMIOLOGY
• RELEVANT ANATOMY
• PHYSIOLOGY
• PATHOPHYSIOLOGY
• CLINICAL FEATURES
• INVESTIGATIONS
• TREATMENT
• CONSIDERATIONS
• CONCLUSION

3. –Samuel David Gross- 1866
“If a surgeon should be so foolhardy as to undertake it
[thyroidectomy] … every step of the way will be
environed with difficulty, every stroke of his knife will
be followed by a torrent of blood, and lucky will it be
for him if his victim lives long enough to enable him to
finish his horrid butchery.”

4. INTRODUCTION
• The term GOITRE refers to any enlargement of the thyroid
gland
• It may be diffuse or nodular and associated with normal,
reduced or exaggerated thyroid function
• In a simple multi nodular goitre the gland is enlarged,
multinodular, thyroid function is not exaggerated and non
neoplastic.

5. HISTORY (1)
• GOITER ( guttur - throat in latin )
• First described in China in 2700 BC
• Thyroid Function
• Da Vinci – thyroid is designed to fill empty spaces in the neck
• Parry – thyroid works as a buffer to protect the brain from surges in blood flow
• Roman physicians – Thyroid enlargement is a sign of puberty
• CURES
• “application of toad’s blood to the neck”
• “stroking of the thyroid gland with a cadaverous hand

6. HISTORY (3)
DATE EVENT
500 AD
ABDUL KASAN KELEBIS PERFORMED THE FIRST THYROID
EXCISION IN BAGHDAD
1200 AD
HOT IRON THROUGH SKIN,PATIENT TIED TO THE TABLE,
INVARIABLY FATAL
1646 AD
WILHELM FABRICUS ,THYROIDECTOMY WITH STANDARD
SURGICAL SCALPELS,PATIENT DIED AND HE WAS
IMPRISONED
1820 AD
JOHAN STRAIB AND FRANCOIS COINDET NOTICED THAT
SEA WEED REDUCED GOITRE SIZE AND VASCULARITY
1830 AD
GRAVE AND VON BASEDOW DESCRIBED GOITRE,
EXOPHTHALMOS AND PALPITATIONS -MERSEBURG TRIAD

7. HISTORY (3)
• 1883
KOCHER performs a retrospective review
•5000 career thyroidectomies
•Mortality rates decreased
–40% in 1850 (pre-Kocher & Bilroth)
–12.6% in 1870’s (Kocher begins practice)
–0.2% in 1898 (end of Kocher’s career)
•Many patients developed cretinism or myxedema
• “ …the thyroid gland in fact had a function….” 1883

8. EPIDEMIOLOGY
• Commoner in women than in men.
• Endemic goitre exist when >10%
• Iodine deficiency, goitrogenic food, genetic
factors, other micronutrients deficiency
Mountainous regions
•Sporadic goitre occurs in non endemic areas
• Goitrogenic substances, physiologic events

9. EPIDEMIOLOGY (2)
Factor OGBERA et al AMAMBRA et al
Male : Female 1 : 5 1 : 6.3
Mean age 40 40.3
Simple 54.7% 63.2%
Reason for presentation Cosmetic Cosmetic
Most common complication Airway Obstruction ( 13%) Airway obstruction
Centre LASUTH ( Lagos) UPTH ( Rivers)

10. EPIDEMIOLOGY
REGION PREVALENCE
ZITENGA, BURKINAFASO 55.2%
SEKOTA, ETHIOPIA 28.6%
PLATEAU STATE, NIGERIA 1- 23 %
NAMIBIA 14.3%
WEDZA, ZIMBABWE 10%
HARARE 10%

13. SURGICAL ANATOMY

21. HISTOLOGY

23. SYNTHESIS
• Step 1 - organification
• Step 2- oxidation
• Step 3- coupling
• Step 4- hydrolysis
• Step 5 - deiodination

24. SYNTHESIS

25. TBPA
TBG
TBA .
TRANSPORT

26. SECRETION
• Normal human thyroid secretes about:
80mg of T4/day
4mg of T3
2mg of RT3

28. FUNCTIONS OF
THYROXINE
• It activates nuclear transcription of genes.
• Increases Na, K-ATPase
• Increase number and activity of
mitochondria.
• Promote growth of the brain during fetal life
and first few years of postnatal life.

29. THYROID HORMONE ON
SPECIFIC BODILY MECHANISMS
1. carbohydrate metabolism
- rapid uptake of glucose by cells
- glycolysis
- gluconeogenesis
- rate of absorption from GIT
- Insulin secretion.
2. Fat metabolism
- mobilization of lipid from fat tissue
- Accelerates the oxidation of free fatty acids by the cells.
3. Vitamin metabolism
- demand for vitamins
Vitamin deficiency in the presence of thyroid hormone secretion.
4. BMR

30. CLASSIFICATION OF
GOITRE
• Simple
.Diffuse hyperplastic Goitre
.Multinodular Goitre
• Toxic Goitre
.Diffuse Toxic Goitre (Graves)
.Toxic multinodular Goitre
.Toxic nodule/adenoma
3/30/2012 30

31. CLASSIFICATION OF
GOITRE
• Inflammatory -
• Autoimmune - e.g Hashimotos thyroiditis
• Fibrosing - e.g Reidel’s
• Infectious - acute or chronic
• Granulomatous - e.g de Quervains
• Neoplastic -
-benign/malignant
3/30/2012 31

32. PATHOGENESIS OF
SMG
• Chronic/sustained Iodine insufficiency initially causes diffuse
hyperplasia & hypertrophy of the thyroid follicular cells under
the influence of increased TSH secretion in an effort to
produce more thyroid hormones.
• This is followed by a period of involution which in turn , under
sustained iodine lack, is followed by further hyperplasia.

33. PATHOGENESIS (2)
• These cycles of repeated hyperplasia & involution from
fluctuating TSH stimulation leads to the formation of
nodules in the gland, hence nodular goitre....
• Fibrosis, calcification, haemorrhage & malignant
transformation may occur in a nodule

34. PATHOGENESIS
• The iodine in the diet and/or water may be inadequate.
• Absorption of iodine from the gut may rarely be deficient.
• Trapping and concentration of iodine by the thyroid may be
prevented by drugs.
• Foods- vegetables of the genus Brassica(cabbage, turnip),
seaweeds, millet, cassava
• Deficiency of enzymes.
• Childhood head and neck irradiation

35. HISTORY
• BIODATA
• PC - anterior neck swelling * longstanding
• Onset, rate of growth, pain
• Cosmetic embarrassment
• Pressure effects -dysphagia, dyspnoea, stridor, hoarseness
• Toxic symptoms (all systems ) - absent
• Hypothyroidism features-

36. HISTORY (2)
• Neoplasm
• Past medical history - biopsies, radiation exposure,
irradiation,
• Diet history - iodized salt, goitrogens
• Family history - MEN 2A,2B ;enzyme deficiencies,
• Drug history- goitrogenic drugs

37. EXAMINATION
• GENERAL- voice, body build, mental state, eyes
• VITAL SIGNS - pulse (rate, rhythm and character )
• THYROID GLAND
• Inspection- Enlarged, moves with swallowing, no skin changes ,dilated veins
with retrosternal extension,
• Palpation - non tender, central trachea, firm, multinodular, retrosternal
extension, negative berry’s sign, lymph nodes,
• EYES- nil exophthalmos, lid retraction or lag; extra ocular muscles ,
• HANDS - no sweating, tremors, no finger clubbing
• REFLEXES- normal
• SYSTEMIC EXAMINATION

38. W.H.O. CRITERIA FOR THE
GRADING OF GOITRES
• GRADE 1.- Goitre can be felt.
-la: Goitre can be felt but is not visible, even with the neck
extended.
-Ib: Goitre can be felt and is visible with neck extended, not
visible with neck in normal position
• GRADE 2: Goitre easily visible with neck in normal position
• GRADE 3: Very large goitre

39. INVESTIGATIONS
1. TFT
2. THYROID USS
3. TECTINUM SCAN
4. FNAC
5. X-ray of neck. & thoracic inlet
6. Laryngoscopy
7. CXR & ECG if >40yr
8. CT scan, MRI
9. FBC, E/U/Cr, RBS,
39
AP
LAT

40. THYROID USS
• COULD IDENTIFY NODULES
AS SMALL AS 2-3 MM
• NON CLEAR CUT
EXAMINATION FINDINGS
• GUIDE FNAC
• MONITOR SMALL NODULES
• DETECT RECURRENCE
• DETECT ENLARGED LYMPH
NODE
WHITE ARROWS SHOW MULTIPLE
WELL MARGINATED NODULES

41. CHEST RADIOGRAPH

42. CERVICAL X-RAY
VIEW DEMOSTRATION
AP TRACHEA DEVIATION CALCIFICATIONS
LATERAL
TRACHEA COMPRESSION CERVICAL
SPINE CHANGES
THORACIC
INLET
RETROSTERNAL EXTENSION

44. THYROID
SCINTIGRAPHY
• Radioisotope of iodine
I or technetium-99
pertechnetate Tc
123
99

45. LARYNGOSCOPY
• Direct or Indirect Laryngoscopy is indicated in goitre
• Detect recurrent laryngeal nerve palsy
• To differentiate laryngeal lesions
• For medicolegal reasons prior to surgery.

47. DIFFERENTIAL
DIAGNOSIS
• Other types of goitre
• thyroid tumours
• Thyroglossal cyst
• Lateral aberrant thyroid
• Carotid tumour
• Sternocleidomastoid tumour
• Lymphoma

48. TREATMENT
• SURGERY is the treatment of choice
• INDICATIONS -
• Cosmetic reasons
• Pressure symptoms or signs
• Retrosternal extension
• Suspicious FNAC
• Enlarging dominant nodule
• Toxicity develops (Plummer’s disease)

49. SURGICAL OPTIONS
• TOTAL THYROIDECTOMY involves excision of all thyroid
tissue (involvement of both lobes, compressive symptoms,
suspicious nodules, history of head and neck radiation)
• NEAR-TOTAL THYROIDECTOMY involves complete
excision one side while leaving a rim(1 - 2 g of thyroid tissue
laterally on the one side, which incorporates the parathyroid
• SUBTOTAL THYROIDECTOMY leaves a rim(4g) of thyroid
tissue bilaterally to ensure parathyroid viability and avoid
entrance of the recurrent laryngeal nerves into the larynx

50. COMPARISON
SUBTOTAL
THYROIDECTOMY
NEAR TOTAL
THYROIDECTOMY
TOTAL
THYROIDECTOMY
THYROID
HORMONE
REPLACEMENT
RECURRENCE
REXPLORATION
MALIGNANT RESID
UAL
ACCIDENTAL
INJURY(RLN)
HYPOCALCEMIA
FOLLOW UP
0.2% 0.3-1.7%
5%
1% 5%
100%25%

51. PRE -OP
• It is an elective surgery. General condition should be
satisfactory;
• PCV, E/U/Cr, RBS , serum Calcium
• CXR, ECG, Indirect Laryngoscopy
• Patient is confirmed euthyroid
• Counseled & consent obtained
• Elective except in e.g sudden haemorrhage within a nodule

52. SUBTOTAL
THYROIDECTOMY
• Anaesthesia- General with
ETT
• Position- hyper-extended
position
with a sandbag behind
shoulder and foam ring
behind the occciput
• Cleaning, draping and marking
3/30/2012 52

53. •Raise subplatysmal flaps up to suprasternal notch
& thyroid notch.
• From the right the surgeon
makes a deep sweeping
incision along the skin
crease
• to the areola tissue
plane
• Ligate/ cauterize bleeders
• Insert a self retaining
retractor to hold flaps apart
• Fig: Flaps raised

54. Details of procedure
• Strap muscles are retracted laterally or divided high up
between (why and when?)
• The investing & pretracheal fascia are opened up in turn until
the gland is reached.
• Gland is freed & mobilized by inserting two fingers laterally
delivering it into the wound
• It is customary to start the excision on the right or the larger
side.

55. 3/30/2012 55

56. Mobilised thyroid gland
3/30/2012 56

57. Details of procedure......
• The upper pole is mobilized & using large curved artery
forceps(3), the arteries are doubly ligated near the gland;
1 of the ligatures a transfixing one & the pole excised
• The middle vein is then looked for & ligated
• The isthmus is also divided btw clamps & removed with the pyramidal lobe
• The inferior veins
• Identify the recurrent LN
• Using curved artery forceps, the gland is picked up deep into the
parenchyma circumferentially leaving only about 4g of tissue with its
capsule behind in the region of the inferior parathyroid.

58. PROCEDURE
• Rest of thyroid is excised with
a knife & the remnant closed
with fine silk.
• Gland is being excised

59. • The left side is then similarly freed & procedure
repeated.
Fig: Thyroid excised
.

64. CLOSURE
• The wound is repeatedly irrigated with saline & the field
inspected for evidence of bleeding.
• Strap muscles are re-approximated if cut
• Incision in pretrachea fascia is closed and the
strap muscles approximated in the midline with interrupted
suture.
64

65. CLOSURE
• A closed suction silastic drain is
left.
• The platysma is closed
• finally the skin using absorbable
subcuticular suture
• Thyroid dressing is applied.
• Fig Sutured wound with a
drain in situ

66. Mention Total & NearTotal Thyroidectomy
Axioms of thyroid surgery –include:
• A meticulously dry operative field must be maintained.
• Tissue in the region of the recurrent laryngeal nerve should
not be cut or clamped until the nerve is definitively identified or
indiscriminate diathermy use avoided.
• If malignancy is suspected, the entire operation should be
done as if the lesion were cancer
3/30/2012 66

67. POST OPERATIVE
CARE• Visualization of the vocal cords at extubation !
• Adequate precaution to prevent hyperextension of the neck
• Oxygen should be available at patients bed side
• A bell and materials for removal of sutures and evacuation of clots
• A sterile tracheotomy set should always be available in the event of a tracheal
collapse
• Parenteral fluids until able to take orally
• Observe and monitor drain ( 24 - 48 hrs )
• Peri-oral numbness
3/30/2012 67

68. COMPLICATIONS
• INTRA-OPERATIVE - RLN damage, haemorrhage
• Early
a. Respiratory obstruction may be due to:
1.Haemorrhage
2.Bilateral abductor paralysis of the vocal cords from damage of the
recurrent LN
3.Tracheal collapse
4.Oedema of the larynx from ETT trauma
5. Nerve of amelita
b. Recurrent laryngeal nerve injury
c. Hypoparathyroidism (accidental removal- identification and remedy
on table)
d. Wound infection

69. COMPLICATIONS (2)
• LATE
• Hypothyroidism
• ( supplemental
• replacement dose
• suppression dose- kesieme
• Keloid scar
• Recurrence
• PREVENTION
• IODINE SUPPLEMENTS
Indication Dose
Supplementary 12.5
Replacement 0.1
Myxedema IV 300-500
Temporary
Subclinical
Permanent

70. CONSIDERATIONS
• Recurrence
• Primary vs secondary retrosternal goitre
• Median sternotomy for retrosternal goitre
• Primary Endoscopic thyroidectomy
• Scarless thyroidectomy

72. CONCLUSION
• Simple multi nodular Goitre though very disfiguring, can be
satisfactorily treated with good outcomes and low morbidity
& mortality in experienced hands.

73. REFERENCES
• Pubmed publications
• Schwartz’s principle of surgery
• Principle and practice of surgery. (Badoe)
• Clinical Surgery. (A. Cuschieri)
• Bedside Clinics in Surgery (Makhan Lal Saha)
• Nigerian journal of surgery
• World journal of surgery
• Zollingers atlas of surgery