Clinical data: A 61-year-old woman was referred for evaluation of nodular goiter. She underwent on bilateral subtotal thyroid resection for 27 years because of a multinodular goiter. She noticed a slowly increasing (over decades) mass in the right thyroid. She had already difficulties in swallowing.

Palpation: Both lobes were nodular on palpation.

Result of blood test: euthyroidism on daily 112.5 microgram levothyroxine (TSH 1.08 mIU/L).

Ultrasonography. The right lobe was moderately hypoechoic while the left was echonormal. A large, less hypoechoic nodule occupied almost the entire right lobe. The nodule presented many hyperechogenic granules and line which corresponded to fibrosis. There were multiple small hypoechogenic lesions in the left lobe.

Aspiration cytology was performed from the nodule in the right lobe and from the hypoechoic lesion in the dorsal part of the left lobe and resulted in benign colloid goiter in both cases.

We had doubt whether the compression signs were caused by the goiter but could not exclude this possibility. Further examinations (including gastroscopy and ear-nose-throat examination, neurological examination) revealed no abnormalities responsible for the complaint. We offered either ethanol sclerotherapy or reoperation. The GP of the patient administered ex juvantibus omeprazole therapy. Two weeks later, the difficulties in swallowing have resolved. In the next 2 years this problem recurred three times and was successfully treated with H2 antagonist.

Nevertheless, it seems likely that the right thyroid will further increase in size and the patient will undergo on reoperation.

Comments.

1. 1. This is a very good example of the drawbacks of the so-called function sparing surgery in the case of a multinodular goiter.

2. 2. An experienced general practitioner is the clue of a health care system and cannot be replaced by evidence-based medicine or with dozens of otherwise justified examinations...