Surgical Management of Larges Goiters in the ENT Department of CHU Mother and Child “Luxembourg”

Objectives: To study the clinical and therapeutic profiles of voluminous goiter. Patients and Methods: We carried out a descriptive and prospective study, relating to a series of 30 cases of voluminous goitre, collected in the Department of Otorhinolaryngology and cervicofacial surgery (ENT and CCF) of the CHU Luxembourg Mother Child of Bamako. It has been spread over a period of 4 years from January 2015 to December 2018. Patients of all ages operated for large goitre at the ENT Department of CHU Luxembourg Mother Enfant were included. Results: In 4 years we collected 30 cases of voluminous goitre; during this period we realized 180 thyroidectomies, complications of the type of hematoma of the lodge in 3.3% of cases, the release of the operative wound in 10% of cases local superinfection in 7.1%. Signs of hypothyroidism were common with 50.0%. Postoperative nasofibroscopy found good vocal fold mobility in all patients. Conclusion: The large goiters have become rare because of the early management of thyroid nodule. Its management must allow the prevention of recurrent and parathyroid morbidity.


Introduction
Goitre refers to diffuse normal thyroid hypertrophies (absence of hyper-or hypothyroidism), non-inflammatory (excluding thyroiditis), and non-cancerous, It consists of initially homogeneous thyroid hyperplasia, clinically latent [1], Radiologically it is defined by an ultrasound thyroid volume of 18 ml in women, 20 ml in men [2]. The proportion of goiter is 4 to 5 times higher than in females [1] [3].
The classification of goiters has been made by WHO ranging from stage I to stage III. Bulky goitre or goiter type III is defined as being visible more than five meters away. The semiological richness is the corollary of an increase in volume as well as its multi-nodular character. This increase causes compression at the tracheal, oesophageal, recurrent nerve and deep veins. This results in a clinical spectrum characterized by dyspnoea, dysphonia or even an upper vena cava syndrome [4].
These symptoms appear gradually and are life-threatening, especially when the development is intra-thoracic [5].
Imaging assessments, namely ultrasound, CT and chest and lateral radiography, form the bedrock of giant goiter management. They allow highlighting signs of malignancy, to weave the relation with the neighboring organs and to objectify an intrathoracic prolongation [1] [2].
Thyroid surgery has a privileged place in the treatment of multiple thyroid diseases, especially in cases of thyroid cancer, but also bulky nodule, compressive goitre, diving or toxic [6].
It is up to the surgeon to set up a protocol for surgical management. This requires a multidimensional approach [7].
The nosology of giant goiter remains a subject little discussed by the literature In view of the problem posed by the management of giant goiters by surgeons, we brought elements contributing to the rationalization of a therapeutic strategy that could contribute to the reduction of the postoperative complication rate.

Patients and Method
We conducted a descriptive and prospective study, involving a series of 30 cases of giant goiter, collected in the department of otorhinolaryngology and cervicofacial surgery (ENT and CCF) of CHU Mere Enfant Luxenbourg, Bamako, over a period of 4 years from June 2015 to June 2018. We are based on the clinical and radiological criteria for the diagnosis of large goiters.
Have been included: Patients of all ages operated on for a large goitre at the ENT department of CHU Mère enfant luxanbourg whose weight of the surgical specimen was greater than or equal to 500 mg. Patients whose mobility of the larynx is preserved preoperatively.
Have been excluded: Inapplicable files, Non operated patients, Thyroid cancers.

Epidemiological Aspects
The frequency: In 4 years we collected 30 cases of voluminous goitre, during this period we performed 180 thyroidectomies, a frequency of 16.67% of cases, The mean age was 51.37 years with an extreme ranging from 37 to 65 years and a standard deviation of 7.97 (Table 1). Females were common in 66.7% of cases with a sex ratio 0.50.

Clinical Aspects
Reason for consultation: All patients consulted for cervical swelling.
The duration of evolution: The long duration of evolution was 40 years in one case the average duration was 18, 20 years.
The family history of goiter was found in 4 cases or 13.3%.
Signs of compression: The sign of compression was found in 85.7% (Table   2).

The Physical Examination
The physical examination found a mobile swelling, hard and painless in all patients is 100%, Goitre was unilateral in 26.7% of cases ( Figure 1) and bilateral in 73.3% of cases ( Figure 2). Endolaryngeal examination was normal in all patients, there was no cervical lymphadenopathy.

Paraclinical Aspects
The lower diving pole was found in 12 cases at CT, All our patients were euthyroid. The classification of TIRADS 2 was found in 80.0% of cases, Filtration was not performed in any of our patients (Table 3).

Therapeutic Aspect
Surgical treatment: Total thyroidectomy was common in 50.0% of cases (Table 4).
Extreme weight was 500 g and 800 g with an average of 586.67 g and a standard deviation of 81.93 (Figure 3), The size of the largest workpiece was 14 cm, The internal jugular vein lesion was found in 8 cases, ie 26.7%, Colloid adenoma of the thyroid was found with 100% of cases.
The postoperative course: We noted a case of the hematoma of the box is 3.3%; 3 cases of the release of the operative wound is 10% and 2 cases the superinfection is 7.1%. Signs of hypothyroidism were common with 50.0% and   The average age of our patients is close to that of MAKEIEFF M who was 60 years old [9], KEITA MA [11] and KEITA I did not share this finding, the average age of 40.9 years is lower than that of our series. The female predominance is the preserve of goitres reported by KEITA MA [11] and MAKEIEFF M [9].

Socio-Epidemiological Aspects
The age of goitre progression according to KEITA MA [11] has been more than 20 years in 53% of cases and according to MAKEIEFF M has been 25% for 15 years, in 25% of cases for more than 30 years and in 25% of cases for less than a year. The long evolution time has been 40 years in our series.

Clinical Aspects
Clinical findings in our patients have revealed a mobile swelling. However, signs of compression such as dysphagia and dyspnea of decubitus due to the development of goitre have been reported in our patients as in other series [9], The characteristics of the swelling, the associated signs and the laryngeal mobility make it possible to direct the ENT surgeon to make histological hypotheses, The family history of goiter was found in 4 cases, or 13.3%, unlike the KEITA I series which reported 13.7% [12], In front of this antecedent one must look for the medullary carcinoma, a deficiency in iodine [5].

Paraclinical Aspects
Paraclinical explorations of large goiters are based on tomodensitometry, thyroid echography, and thyroid hormone testing [5], The cervico-mediastinal com-  Computed tomography has not been systematic in the MAKEIEFF M series, it has made it possible to recover the plunging character of goiter as well as MRI [9]. The esogastroduodenal transit was indicated by MAKEIEFF M in cases of goitre associated with dysphagia [9], Computed tomography was performed in four (4) cases corresponding to diving goitres.
Cervico-mediastinal CT is part of the extension assessment of thyroid cancers and large and/or plunging goitres [1] [5], MRI has several strengths: excellent tissue contrast; no interference of gadolinium with thyroid function and isotopic explorations. These indications of choice are therefore: precise exploration in case of goiter goiter; the extension assessment of thyroid cancers; the search for post-surgical tumor recurrence [5].
The ultrasound criteria were of a contribution in the management of giant goiters, giving the criteria of malignancy or benignity according to the classification TIRADS.
The main criteria predicting malignancy: are the solid character and hypoechoic appearance, micro-calcifications, irregular contour or fuzzy boundaries, absence of a peri-nodular halo, nodule higher than broad, intra-nodular vascularization. It is important to note that for the moment, none of these studies has made it possible to define the relative importance of these different criteria [5] [13].

Therapeutics Aspects
 Access way and type of thyroidectomy All our patients were operated under general anesthesia. The approach was an exclusive anterior cervicotomy. Total thyroidectomy was the most frequent indication with 50.0% in our case as in the series of KEITE A who reported 60% of cases [14] and in the series MOULOUDJI L and MAHMOUDI H who reported 89% of cases [15], In the BENBAKH M. and al series, total thyroidectomy in 98% [16], In other series the thyroidectomy was partial [17]. Ultrasound data based on the TIRADS classification guided our therapeutic indications.
In the MAKEIEFF M series the mean weight of goiter was 175 grams with a maximum of 800 grams and the size was between 6 and 15 cm for the largest [9], In the BENBAKH M et al series, the average weight of goiters was 205 grams with a maximum of 820 grams. The size was between 5.3 cm and 19 cm for the largest [16]. For Koumare AK; the average weight of goitres was 320 grams [17]. These data are close to those of our patients. In patients with signs of compression in our series, goitre was voluminous. The same observation has been noted in some authors [9].
The volume of goitre can change the operative sequence. The problems associated with diving and giant goitre are of a recurrent and parathyroid nature. Prevention of recurrent morbidity is imperative [5].

Operating Incidents
In giant goiters, the exteriorization of the gland towards the midline to perform the recurrent search is difficult. This act is responsible for stretching and nerve Int. J. Otolaryngology and Head & Neck Surgery traction. The retrograde pathway was the main mode of dissection. In the absence of a recommendation on this subject we prioritized it. Several authors agree that the recurrent approach sought is the retrograde pathway in cases of giant goiter, diving and in cases where the classical path is impossible [18], It always allows to locate the nerve without stretching, Thyroid surgery is the prerogative of the complications we have identified cases of jugular injury, These are goitres that compressed the vasculo-nervous axis with adherence to a thyroid capsule, Intraoperative haemorrhage was observed in the KOUMARE AK series in 12% [17], Several factors explain the hemorrhagic risk of giant goiters. These include hypervascularization of the thyroid parenchyma, more pronounced dilation of the peripheral vessels, the very close relationship with the jugulocarotidian axis and overflow on the aortic arch [6] [17].  Postoperative follow-ups Final recurrent paralysis and hypocalcemia were noted in the KOUMARE AK series. In our case, no definitive recurrent and parathyroid lesions were noted.
Hypocalcemia varies in the literature between 1.6% to 50% according to JAFARI M [19]. Whether transitory or definitive, is a usual complication [6], It occurs as a result of parathyroid parenchymal excision and devascularization of the parathyroid glands at the time of dissection. Hypocalcemia was transient in 7.1% in our series.
The operative sequences in some cases were enamelled with hypothyroidism.
Total thyroidectomy exposes the same mortality and morbidity risks as subtotal and prevents the risk of tumor recurrence [20], In our series hypothyroidism following total thyroidectomy is the illustration of treatment nonobservance due to low income of the population.
The benign histological nature concerned the colloid adenoma with 100% of cases. This histological aspect corroborates with that of MAKEIEFF M [9] MOULOUDJI L and MAHMOUDI H which reported 97.46% [15] contrary to the series of KEITA I [12] which found colloid adenoma in 63.8% of cases.

Conclusion
The large goiters have become rare because of the early management of thyroid nodule. They impose surgical excision most often cervical in our context. A systematic clinical and radiological examination makes it possible to make the diagnosis. Its management must allow the prevention of recurrent and parathyroid morbidity.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.