Clinical data: An 82-year-old woman was referred for valuation of an extremely large goiter which was developed after a severe psychological trauma 11 years ago. It was then that she was diagnosed with hyperthyroidism, she has been taking medication ever since. The proposed surgery was then rejected by the patient. Over time, the patient experienced a slow growth of the goiter and difficulties in swallowing has appeared.

Palpation: an extremely enlarged thyroid with multiple nodules.

Laboratory tests: TSH 12.7 mIU/L, FT4 5.11 pM/L on daily 20 mg methimazole.

Ultrasonography disclosed an extremely enlarged goiter in both lobes and in the isthmus. The thyroid was composed of multiple nodules. The dimensions of the right lobe were 200x120x150 mm, those of the left lobe were 120x70x130 mm, width, depth, length, respectively. The isthmus was 45 mm deep. The lower pole of each lobe was not visible.

Neck and upper mediastinal CT scan disclosed that the thyroid extends 18 cm below the level of the clavicula.

Suggestion: After stopping thyrostatic treatment for one week, take 10 mg methimazole daily, hormone monitoring after five weeks. Surgery after normalization of FT4.