Clinical data: A 68-year-old woman came to a routine follow-up. First, we met her 9 years ago when an enlarged, multinodular goiter was detected. The dimensions of the right lobe were 38x32x65 mm, width, depth, length, respectively. Aspiration cytology resulted in benign colloid goiter. Considering the degree of enlargement and the substernal spread, surgery was advised. The patient refused our suggestion because she had no complaint. In the upcoming years, we met her 3 times and no progression was detected. This time, 3 years after the last visit, the patient told us that difficulties in swallowing has appeared.

Palpation: The right lobe and the isthmus had multiple, not firm nodules.

Laboratory tests: TSH 2.17 mIU/L, FT4 13.3 pM/L.

Ultrasonography disclosed an enlarged right lobe with the dimensions of 40x48x80 mm, width, depth, length, respectively. This lobe was composed of multiple echonormal nodules. The left lobe was normal-sized and had a minimally/moderately hypoechoic subcentimeter lesion. The ratio of the narrowest and broadest diameter of the neck section of the traches was 13 to 22 mm. The lower pole of the right lobe could not be visualized in all longitudinal section.

Cytology resulted in benign colloid goiter.

Neck and upper mediastinal CT scan disclosed that the thyroid extends 5 cm below the level of the clavicula.

Considering the CT scan, the surgeon believed that the right lobe could be removed from the neck incision and he was right. Right lobectomy was performed.  Histopathology disclosed benign hyperplastic nodules.

Comment.

1. If the lower pole of an enlarged lobe becomes clearly visible during swallowing then it can be safely said that the thyroid gland can be removed by neck excision. If we have any doubt, a neck and upper mediastinal CT scan is mandatory.

2. It is extremely important that the CT finding is reliable and accurately includes the extent of substernal spread. Up to a certain limit, during surgery, the surgeon can also lift the thyroid gland that spreads to the chest from a neck incision.