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, i.e. frequency of 16.67%. The average age was 51.37 years with an extreme ranging from 38 to 65 years. Females were common in 66.7% with a sex ratio of 0.50. The long duration of evolution has been 40 years. The sign of compression was found in 85.7%. The physical examination found a mobile swelling, hard and painless in all patients with normal endolaryngeal examination; there was no cervical lymphadenopathy. The lower dipping pole was found in 5 cases on CT. All our patients were euthyroid. The classification of TIRADS 2 was found in 80.0% of cases. Total thyroidectomy was frequent with 50.0% of cases. The average weight of the operative specimen was 586.67 g with extremes ranging from 500 g to 800 g. The size of the operative piece of 14 cm was the longest. Injury of internal jugular vein was found in 26.7% of cases. Colloid adenoma of the thyroid was found in 100% of cases, postoperative 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.
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 [
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 [
These symptoms appear gradually and are life-threatening, especially when the development is intra-thoracic [
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 [
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 [
It is up to the surgeon to set up a protocol for surgical management. This requires a multidimensional approach [
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.
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.
➢ Sociodemographic status: age, sex, antecedent
➢ Clinical aspects: functional signs, physical signs
➢ Paraclinical data: biological assessment, Cervical ultrasound and CT
➢ Postoperative results: histological examination of the operative specimen
➢ Patients undergoing total thyroidectomy received thyroid hormone supplementation.
➢ All patients were operated under general anesthesia
➢ The approach was the classic route of thyroidectomy
➢ Opening of the white line
➢ Ligation of the vessels of the superior pole, Identification and preservation of the superior parathyroid
➢ Cricopharyngeal muscle exposure
➢ The recurrent nerve is searched after palpation of the small horn of the thyroid cartilage
➢ The nerve was dissected until it emerged in the chest; ligation of the branches of the inferior thyroid artery, identification and preservation of the lower parathyroid
➢ Depending on which part of the gland is affected by loboisthmectomy or total thyroidectomy
➢ The closure was carried out in two planes
Analysis and data processing: An investigation sheet was established, the consent of patients was previously obtained to participate in the study. The data has been computerized using software specialized in statistical processing “SPSS 21.0 French version”, and the data entry on Word 2013.
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 (
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% (
The physical examination found a mobile swelling, hard and painless in all patients is 100%, Goitre was unilateral in 26.7% of cases (
Age | Effective | Percentage % |
---|---|---|
[30 - 40] | 2 | 6.67 |
[40 - 50] | 12 | 40.00 |
[50 - 60] | 8 | 26.67 |
[60 - 70] | 8 | 26.67 |
Total | 30 | 100 |
Compression Signs | Effective | Percentage |
---|---|---|
Isolated dysphony | 1 | 7.1 |
Isolated dysphagia | 2 | 14.3 |
Isolated dyspnea | 4 | 28.6 |
Dysphagia + dyspnea | 4 | 28.6 |
Dysphagia + dyspnea + dysphagia | 1 | 7.1 |
Total | 25 | 85.7 |
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 (
Surgical treatment: Total thyroidectomy was common in 50.0% of cases (
Extreme weight was 500 g and 800 g with an average of 586.67 g and a standard deviation of 81.93 (
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
Paraclinical examinations | Effective | Percentage |
---|---|---|
CERVICAL CT | 12 | 40.0 |
CERVICAL ULTRASOUND | 30 | 100.0 |
TSH us-T4 | 30 | 100.0 |
Surgical treatment | Effective | Percentage |
---|---|---|
Right Loboisthmectomy | 3 | 10.0 |
Left Loboisthmectomy | 5 | 16.7 |
Subtotal thyroidectomy | 7 | 23.3 |
Total thyroidectomy | 15 | 50.0 |
Total | 30 | 100.0 |
hypocalcemia in 26.7% of cases, Postoperative nasofibroscopy found good vocal fold mobility in all patients.
During 4 years we realized in the ENT and CCF Department of the Mother-Child Hospital Luxembourg 180 thyroidectomies including 30 cases of voluminous goitre, a frequency of 16.67% of cases.
The frequency of large goiters is poorly reported in the literature [
The average age of our patients is close to that of MAKEIEFF M who was 60 years old [
The age of goitre progression according to KEITA MA [
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 [
The family history of goiter was found in 4 cases, or 13.3%, unlike the KEITA I series which reported 13.7% [
Paraclinical explorations of large goiters are based on tomodensitometry, thyroid echography, and thyroid hormone testing [
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 [
Cervico-mediastinal CT is part of the extension assessment of thyroid cancers and large and/or plunging goitres [
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 [
➢ 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 [
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 [
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 [
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 [
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 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 [
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% [
➢ 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 [
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 [
The benign histological nature concerned the colloid adenoma with 100% of cases. This histological aspect corroborates with that of MAKEIEFF M [
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.
The authors declare no conflicts of interest regarding the publication of this paper.
Sidibé, Y., Haidara, A.W., Samaké, D., Kanté, A., Soumaoro, S., Guindo, B., Camara, N., Touré, M.K., Cissé, M., Djibo, A., Diakité, Y.D., Sanogo, B. and Kéïta, M.A. (2019) Surgical Management of Larges Goiters in the ENT Department of CHU Mother and Child “Luxembourg”. International Journal of Otolaryngology and Head & Neck Surgery, 8, 139-149. https://doi.org/10.4236/ijohns.2019.84016