Endocrine Abstracts

A 45-year-old lady from the Iodine - deficient Himalayan belt presented to us with a gradually progressive, painless goiter for more than 20 years. Such goiters were common in her village. She neither had symptoms of hyper/hypothyroidism nor any compressive symptoms. She had four living issues and as per her, the goiter would increase in size during the second trimester of each pregnancy. On examination, she had a huge thyroid swelling involving both lobes and isthumus, measuring 20 ×20 cm with dilated veins over the swelling. The swelling was firm in consistency, moving with deglutition and had no retrosternal extension. There was no cervical lymphodenopathy. The diagnosis of an euthyroid multinodular goitre was made. Thyroid profile was normal; however, vocal cords could not be visualized during video laryngoscopy. CECT should retro tracheal extension. She underwent total thyroidectomy under General anesthesia. A 2-kilogram goiter was excised in toto, and the surgery lasted for 8 hours. Bilateral recurrent laryngeal nerve (RLN) and all four parathyroid glands were identified and preserved. However, intraoperatively she was found to have tracheomalacia hence, tracheostomy was done. She developed biochemical hypocalcemia on POD 2 and was started on oral calcium and vitamin D supplementation to which she responded well and became eucalcemic. Video laryngoscopy on POD 4 showed U/l paresis so tracheostomy care was continued. Video laryngoscopy on POD 12 showed bilateral vocal cords mobile, hence, she was weaned off tracheostomy gradually and was decannulated successfully on POD20. During the ICU stay patient developed ICU psychosis and required psychiatric care. Histopathology was reported as multinodular goitre. She now has normal voice, is eucalcemic and on thyroxine replacement. This case highlights the importance of thorough counselling of such patients with long standing goitre as these can cause tracheomalacia. Surgery in such cases requires utmost patience and always requires holistic hospital care by a multidisciplinary team. We almost lost the patient because of ICU psychosis when she became violent and tried to remove the tracheostomy tube by herself. Since these women are never exposed to hospital environment, she developed psychiatric rage and had to be treated accordingly.

Learning Points: 1. Most of these goiters benign2. Iodine Deficient belt3. Huge MNG4. Most women anemic5. Intubation difficult-Awake preferred6. Liberal incision7. Strap muscles to be cut8. RLN mostly on the surface9. Tracheomalacia is common10. Excess skin needs to be removed