Massive multinodular goiter with stridor.

Sir,

A 62-year-old lady presented with progressively increasing huge swelling in front of her neck for past 15 years. Her symptoms worsened in the last week prior to presentation with stridor and breathlessness on exertion. She also complained of dragging sensation and hoarseness of voice for 6 months. She did not have any features to suggest thyroid hormone deficiency or excess. She denied history of throat pain, dysphagia, fever and any other systemic complaints. Examination revealed normal vital parameters with oxygen saturation of 92%. Local examination revealed a large multinodular goiter with areas of solid and cystic feeling extending into the intrathoracic region [Figure 1]. However, Pemberton's maneuver was negative indicating no compression on great vessels. Rest of the systemic examination was normal. Hormonal profile revealed normal thyroid function and CT scan showed a heterogeneously enhancing space-occupying lesion of 11 × 7 × 6 cm in size with calcific foci, preserved capsule with partial tracheal compression [Figure 2]. The swelling extended up to angle of the mandible laterally, anterior to the sternum with small intrathoracic extension inferiorly. She was diagnosed as a case of colloid goiter. She underwent excision of the swelling and had a difficult intubation preoperatively. The entire thyroid mass was excised which had a weight of 2.8 kg. Postoperative course was uneventful with no requirement for tracheostomy. Histopathological examination of the specimen revealed benign colloid goiter. Postoperatively her hoarseness of voice improved and she had no features of hypoparathyroidism.

Figure 1

Clinical photograph.

Figure 2

CT scan of neck showing massive MNG.

Benign goiter leading to airway compromise has become a rare entity now. Universal salt iodisation, early diagnosis of thyroid disorders, cosmetic concern and improved surgical technique with minimal disfigurement lead to disappearance of monstrous goiter from clinical practice.[1] Airway compromise is rare in benign goiter without any associated complications as seen in our patient. Progressive enlargement of goiter leads to adaptation with minimal breathlessness. Sudden worsening of breathlessness is due to hemorrhage into the cyst, infection or tracheal collapse. Spirometry is suggested as part of diagnostic work up in all cases of huge goiters.[2] The incidence of upper airway obstruction ranged between 10 and 30% using spirometry. Partial or total thyroidectomy leads to complete resolution of the obstruction.