Pits and pearls in the management of giant goiters

Abstract

Objective: Giant goiters invariably have been neglected by the patients allowing them to grow to huge sizes. Usually, these are slow growing and are not troublesome, and hence, the patients ignore them. The treatment of such goiters is surgery. However, when these become >10 cm, they pose challenges to the patient, the anesthetist, and foremost the surgeon. Materials and Methods: We present here a single-institutional experience of managing 13 monster goiters. Harmonic scalpel and bipolar cautery were used intraoperatively. The surgical loupes were used in all cases for identification of the nerves. Their clinical presentation, salient symptoms and our experience, and key factors affecting successful outcomes were analyzed. Results: Ten patients had benign lesion and three harbored malignancy. All patients were made euthyroid before surgery except one in whom the indication for surgery was thyrotoxicosis. All patients underwent awake fiber-optic intubation. Four patients underwent total thyroidectomy, two underwent hemithyroidectomy, and remaining underwent subtotal thyroidectomy. One patient required sternotomy for retrosternal extension of the goiter. Harmonic scalpel and bipolar cautery were used intraoperatively. Surgical loupes were used in all cases for identification of the nerve. In all cases, recurrent laryngeal nerve was identified. Tracheomalacia was noted in two patients, and only one of them had to be tracheostomized postoperatively. Conclusion: Anatomy was found to be distorted in all our cases. Identifying the nerve was difficult due to distorted anatomy. Transient hypocalcemia was a consistent feature in spite of identifying the parathyroids and preserving its blood supply. Cases with tracheomalacia and bilateral vocal cord palsy can pose challenge for extubation, and tracheostomy needs to be considered in them.