ABSTRACT

Iodine deficiency is one of the known causes of nodular goiter

worldwide; sizes and weights are also dependent on dietary intake of iodine.
Multinodular nontoxic goiters are usually asymptomatic in some but with
observable growth of the thyroid. Prompt consultation and treatment are
important to prevent further complicitons. Current diagnostics are reliable
and cost effective mostly for benign goiters. Treatment is dependent on the
progression of the disease and health status of the patients; surgeons may
opt for near-total or total thyroidectomy. Multinodular nontoxic goiters can
also be treated with new noninvasive technologies that may be used as
adjunct to previous therapies.
OBJECTIVES:
1. To present the case of L.D.; a case of multinodular nontoxic goiter
2. To briefly discuss the anatomy, physiology/pathophysiology,
management of multinodular nontoxic goiter.
INTRODUCTION:
In iodine deficient areas such as some Italian regions, nodular goiter is
present in 25-33% of the population, its frequency increasing with age.
In iodine sufficient areas the prevalence of nodular goiter is comprised
between 0.4 and 7.2% high in iodine deficient areas and about 4% in
iodine sufficient countries
In the United States, >50% for thyroid nodules. In the Framingham
study, ultrasonography revealed that 3% of men older than 60 years
had thyroid nodules, while 36% of women aged 49-58 years had
thyroid nodules.
The female-to-male ratio is 4:1.(In the Wickham study, 26% of women
had a goiter, compared to 7% of men. Thyroid nodules are less
frequent in men than in women, but when found, they are more likely
to be malignant.
The frequency of goiters decreases with advancing age. The decrease
in frequency differs from the incidence of thyroid nodules, which
increases with advancing age.

CASE PRESENTATION:
GENERAL DATA: This s the case of L.D., a 68 year old, female, married, a
Roman Catholic from Bugallon, Pangasinan, who was admitted at R1MC on
August 11, 2015, 10:20AM
HISTORY OF THE PRESENT ILLNESS:

One month prior to admission, the patient observed an left anterior

neck mass measuring 3x3 cms; movable, nonpulsating, soft, with nodular
surface, no tenderness noted, no fever was noted, no associated difficulty of
breathing. The patient then sought consult at the R1MC OPD Surgical
department and was diagnosed with multinodular nontoxic goiter. Thyroid
ultrasound revealed Thyromegaly with complex cystic mass with mural
nodule suggesting colloid cyst, left associated with co-existing heterogenous
small solid nodule exhibiting borderline features; normal sized right thyroid
gland with n looking thyroid cysts. The patient was then scheduled for
elective surgery and thus, was admitted.
PAST MEDICAL HISTORY: no past medical or surgical histories
FAMILY HISTORY: (-)hypertension (-)DM (-)CA (-)Asthma (-) CVD
PERSONAL SOCIAL ENVIRONMENTAL HISTORY:
The patient is an elementary graduate and is a housewife. She does
not smoke nor drink alcoholic beverages.
PHYSICAL EXAMINATION:
BP: 110/70 CR:89RR:20Temp.:36.5
SKIN: no pallor, no jaundice
HEENT: anicteric sclera, pink palpebral conjunctiva. (+)left anterior neck
mass 3x3cms
CHEST & LUIGS: symmetrical chest expansion, clear breath sounds, no
retractions noted
CARDIOVASCULAR: adynamic precordium, normal rate regular rhythm no
murmurs.
ABDOMEN: flabby, normoactive bowel sounds, soft, nontender
EXTREMITIES: no gross deformities
NEUROLOGIC: GCS15
COURSE IN THE WARD:
1st hospital day: the patient was placed under NPO, IVF:D5LRS. The following
medications were prescribed: Ceftriaxone 1g/IV q12 start 1 hr prior to OR.
2nd hospital day: the patient was scheduled for elective total thyroidectomy.
3rd hospital day: 1st post op day: the patient was afebrile, (+)dysphagia. The
patient was placed on DAT with SAP diet. No IVF. Cefalexin 500mg/cap was
started as well as Mefenamic Acid 500mg/tab TID.

4th hospital day: 2nd post op day: the patient had no other subjective
symptoms except for (+) slight dysphagia and was discharged. OPD follow
up was scheduled on August 20, 2015. Home meds: Calcium tab OD,
Cefuroxime 500mg BID for 7 days, Celecoxib 200mg BID for pain.
http://www.sciencedirect.com/science/article/pii/S0301562915003671
http://www.ajnr.org/content/early/2015/03/26/ajnr.A4276.abstract
http://m.eje-online.org/content/172/2/R47.short
DISCUSSION:
Thyroid Anatomy
- The adult thyroid gland is brown in color, firm in consistency and is
located posteriorly to the strap muscles(sternohyoid, sternothyroid,
superior belly of the omohyoid). It normally weighs approximately
20g. the thyroid lobes are connected via the Isthmus which is
located inferior to the cricoid cartilage. The thyroid is supplied by
the Superior thyroid arteries, inferior thyroid arteries and thyroidea
ima artery. Venous drainage are via the superior, middle, inferior
thyroid veins. Nerve innervation is through the left and right
recurrent laryngeal nerve, superior laryngeal nerve, superior and
cervical sympathetic ganglia. Regional lymph nodes include
pretracheal, paratracheal, perithyroidal, recurrent laryngeal nodes,
superior mediastinal, retropharyngeal, esophageal, upper, middle
and lower jugular chain nodes.
Thyroid Physiology
- Iodine metabolism: daily iodine requirement is 0.1mg. The thyroid
stores 90% of the iodine in the body
- Thyroid hormone synthesis, secretion and transport
o Thyroid hormone function is for fetal brain development and
skeletal maturation, increase GI motility, increase bone and
protein turnover, increase glycogenolysis, hepatic
gluconeogenesis, intestinal glucose absorption, cholesterol
synthesis and degradation.
Goiter
Goiter is an enlargement of the thyroid gland. The gland can be
generally enlarged or have multiple growths/ multinodular leading to
enlargement of the whole thyroid gland. There are two forms of goiter:
1. Toxic multinodular goiter where there is increased levels of thyroid
hormone; greater than TSH levels. 2. Nontoxic multinodular goiter had
normal levels of thyroid hormone.

Clinical manifestations/features
Nontoxic multinodular goiters often present with enlargement of
the thyroid at the neck area.
Toxic multinodular goiters are usually in older patients and those
who had prior history of a nontoxic multinodular goiter

Diagnostics:
Radionuclide imaging: uses Iodine-123 and Iodine-131. These
isotopes are used to screen and treat patients with differentiated
thyroid cancers for metastatic disease. The images provide
information about the size, shape of the gland, and the
distribution of functional activity.
Ultrasound: no radiation exposure. Helpful in the evaluation of
thyroid nodules, distinguishing solid from cystic, size and
multicentricity. It is also helpful for assessing lymphadenopathies
and to guide FNAB.
CT/MRI scan: helpful for evaluating the extent of large, fixed or
substernal goiters(which cannot be evaluated by ultrasound) and
their relationship to the airway and vascular structures.
Treatment:
Radioactive iodine and surgical resection may be used. RAI therapy
is reserved for elderly patients who represent very poor operative
risks, provided that there is no airway compression from the goiter
and thyroid cancer is not a concern. Care must always be observed
when identifying the recurrent laryngeal nerve since injury here
may cause hoarseness of the voice. Near-total or total
thyroidectomy is recommended to avoid recurrence and increased
complication rates with repeat surgery.

CURRENT DIAGNOSTICS AND TREATMENT

Upon comparison between surgical resection and radiofrequency

ablation in the treatment of benign thyroid lesions, researchers
found that with radiofrequency ablation, the patients encountered
less complications, with preserved thyroid function and fewer
hospitalization days.
As part of the management of benign multinodular goiter,
recombinant human TSH(rhTSH) was used as an adjuvant to Iodine131 because it was found to double the uptake of Iodine-131.

CONCLUSION:
The clinical manifestations of each disease differ from one patient to
another. This is also true for patients with multinodular nontoxic goiter.
Patients may present initially with thyroid growth, while others would be
dysphagia or hoarseness of voice. Essential to the diagnosis of would entail
thorough history and physical examination that will be supported by
diagnostics like ultrasound, ct/mri scans, radioactive iodine uptake. Thus,
rapport with patients is important, as well as application of knowledge and
skills of physicians in controlling possible thyroidectomy complications and
the use of their so-calledclinical eye to accurately diagnose and
differentiate toxic from non toxic multinodular goiters. Further studies, should
be done to support the use of new technologies to supplement in the
treatment of patients.

BIBLIOGRAPHY:
Book source: Schwartzs Principles of Surgery 10th edition.
Internet sources:
http://www.ncbi.nlm.nih.gov/pubmed/9019982
http://emedicine.medscape.com/article/120034-overview#a6
http://endocrinediseases.org/thyroid/goiter.shtml
http://m.eje-online.org/content/172/2/R47.short
Hans Graf. February 2015. THERAPY OF ENDOCRINE DISEASE:
Recombinant human TSH and radioactive iodine therapy in the management
of benign multinodular goiter. European Journal of Endocrinology.
http://www.ajnr.org/content/early/2015/03/26/ajnr.A4276.abstract
Che Y, et al. March 2015. Treatment of Benign Thyroid Nodules:
Comparison of Surgery with Radiofrequency Ablation. Amrican Society of
Neuroradiology.