Introduction:
The thyroid gland is typically situated in the front region of the neck. The term goiter is derived from the Latin word tumidum gutter, which means swollen, inflamed throat. The term defines the thyroid gland as swollen double its size, approximately 40 grams. Retrosternal goiter, substernal goiter, intrathoracic goiter, or mediastinal goiter are utilized to define a goiter that expands outside the thoracic inlet. A retrosternal thyroid is the abnormal area of all thyroid or a portion of the thyroid gland that is present down to the breastbone. Smallish benign euthyroid goiter does not require any treatment, but large and complex goiters may need medical therapy and surgical management. Likewise, malignant goiters demand medical therapy and surgical management. Retrosternal goiter is the enlargement and extension of the thyroid gland beyond the thoracic inlet. In this condition, surgery plays a vital role in management methods. Toxic multinodular goiter is an enlarged thyroid that has two or more autonomously acting nodules in it, which produces a large number of thyroid hormones. It is a reason for hyperthyroidism in older patients.
What Are the Causes of Goiter?
An abnormal increase in the size of the thyroid gland causes goiter. The reasons for the enlargement of the thyroid gland involve the following:
-
An overactive thyroid gland this condition is called hyperthyroidism.
-
An underactive thyroid gland. This condition is called hypothyroidism.
-
The formation of lumps or nodules in the thyroid gland might be harmless.
-
Alteration in the hormone levels as it occurs in pregnancy, puberty, or in menopause.
-
Inflammation in the thyroid gland is called thyroiditis.
-
Certain disease conditions of the immune system, like Grave’s disease.
-
Deficiency of iodine in the diet.
-
Thyroid cancers. These cancers are rare.
What Are the Indications of Surgical Management of Goiter?
The most common indication for goiter surgical management is removing the thyroid nodule. This is done if any abnormality is found in fine needle aspiration biopsy. Thus surgery is recommended if the biopsy results show papillary cancer, cancer like follicular neoplasm, any abnormal findings, or the biopsy is inconclusive.
The results of molecular marker testing in biopsy shows there are chances of malignancy. Surgical management is indicated in cases of nodules, even in benign biopsy reports, when the nodule has increased or the nodule is inducing any manifestations like the patient's symptoms like discomfort in that area, difficulty ingesting food, and difficulty in swallowing. Surgery is also indicated in the cases of hyperthyroidism, including Grave’s disease or the presence of any toxic nodule, increased size of nodule or presence of multinodular goiter, or the patient has difficulty and has manifestations regarding goiter.
How Has Preoperative Evaluation Done in the Surgical Management of Goiter?
Before the surgery, the patient is assessed thoroughly.
-
A proper medical history should be taken. A detailed physical assessment should be done. It includes the cardiopulmonary assessment.
-
In the case of older patients, patients above 45 years of age who have manifestations of heart disease, an electrocardiogram and a chest X-ray should be taken before the surgical procedure.
-
Detailed blood tests are done to find if any bleeding disorders are present.
-
In cases of patients whose voice is altered or those who had previous neck surgeries like thyroid, parathyroid surgery, spine surgery, or carotid artery surgery, and also in cases of a patient who is doubted to have invasive thyroid cancer, should be assessed thoroughly for the functioning of the vocal cord regularly before the surgery. This is mandatory to check if the recurrent laryngeal nerves that control the vocal cord muscle are normal.
-
In some rare cases, medullary thyroid cancer is doubted. In these cases, the patient is assessed for tumors in the endocrine gland as a cause of familial syndrome involving adrenal gland tumors called pheochromocytoma, or swollen increased size of parathyroid glands, which secretes a large number of parathyroid hormones. This condition is called hyperparathyroidism.
What Are the Complications of Surgical Management of Goiter?
-
Recurrent Laryngeal Nerve Injury - Postoperative nerve injury when approximated in cases of those who had done goiter excision with those without electrophysiologic laryngeal monitoring. The chance of temporary paralysis is particularly down with monitoring.
-
Hypoparathyroidism - In patients with postoperative hypoparathyroidism, there is the possibility of permanent hypocalcemia after bilateral surgery. In those cases, supplements are given for more than six months.
-
Tracheostomy - It is required in a few cases of patients.
-
Revision Surgery - It is a repeated thyroidectomy procedure, females are more susceptible to thyroid diseases and six times increased susceptibility towards revision surgery.
-
Other Complications - Other goiter surgery complications include a series of hemorrhages demanding ligation and binding of a bleeding vessel. Rarely post-operative subglottic stenosis, transient postoperative atrial fibrillation, and dysphagia occur after the excision of masses inducing esophageal deviation.
What Are the Post-Operative Precautions Taken After Surgery of Goiter?
The patient is asked to reduce extreme physical activities for a few days or a week. This is done to limit the risk of postoperative hematoma formation, which is clot formation. Also, reduce the risk of breakage of sutures and permits wound closure. The patient can do their normal daily activities the next day of surgery. However, strenuous exercises and lifting weights can only be done after a few weeks. In some cases, the patient may develop hypothyroidism following the removal of the thyroid gland. The patient is advised to take thyroid hormone replacement medications in these cases.
Conclusion
Goiter is the enlargement of the thyroid gland. In cases like malignancy or invasive disorders, surgical management is necessary. There are various causes for the development of goiter. It is indicated if a malignancy is suspected or confirmed in the biopsy. Before the procedure, specific measures should be taken to assess the patient. Then following the surgery of the goiter patient can return to normal activities on the next day of the surgery. And in certain cases, if there is a chance of developing hypothyroidism.
