Endocrine Abstracts

Introduction: Most goitres are asymptomatic and do not require surgical intervention. Surgical management is recommended for goitres with compressive symptoms, suspected malignancy, drug-resistant hyperthyroidism, or retrosternal extension.

Case: 63-year-old female with a background history of hypertension, type 2 diabetes, obesity (BMI 43 kg/m²) and possible obstructive sleep apnoea (OSA), presented to Emergency Department following a one-minute episode of apnoea during sleep resulting in peripheral cyanosis, episodes of dyspnoea and stridor. She also had history of partial thyroidectomy in 1993, however no history of thyroid cancer or radiation exposure. CT scan two years prior to admission, showed a multinodular goitre and she was treated with carbimazole for subclinical hyperthyroidism for two years. Clinical examination demonstrated a very large multinodular goitre that was firm in consistency, moving with deglutition. Arterial blood gas on admission showed PO₂ 10 kPa, PCO₂ 5.61 kPa, bicarbonate 30.1 mmol/l, pH 7.48. During the first night of admission, the patient’s SpO₂ level decreased to 60% on room air whilst sleeping. The patient desaturated further to 60% on 4L O₂ on lying down and oxygen saturation improved to 95% on sitting up, and she was subsequently transferred to the intensive care unit for airway monitoring. CT neck and thorax demonstrated a large bilateral multinodular goitre (11x6x1 cm) extending from the neck to thoracic level with predominantly left sided compression of trachea, and the upper neck vascular structures appeared displaced because of the large goitre. Thyroid profile showed free T4 12.1 pmol/l, free T3 5.1 pmol/l TSH 1.37 mIU/l, thereby euthyroid state. The patient was transferred for an urgent Ear/Nose/Throat team review given the significant risk of airway compromise. She subsequently underwent total thyroidectomy without complications. She desaturated on post-op day 1, possibly due to mucous plugging, an element of tracheomalacia, or pre-existing OSA, and was re-intubated for one day. She was then extubated to non-invasive ventilation and the overnight oximetry demonstrated 240 events of desaturation, likely in keeping with OSA. She was discharged on post-op day 9. Her histopathology of thyroidectomy revealed an incidental multifocal papillary thyroid cancer on a background of significant follicular nodular disease and will require ongoing clinical follow-up.

Conclusion: Significant thyroid enlargement, including multinodular goitre, may occasionally cause the upper airway compression, leading to respiratory compromise. Surgical treatment is the management of choice in patients that are surgically fit. Careful post-operative management is important in cases such as this, where a co-existing pathology such as OSA may complicate the clinical picture.