Other edifying cases - Case 14: Different degrees of substernal spread |
Clinical presentation: a 67-year-old woman with toxic multinodular goiter was referred for an evaluation of difficulties in swallowing. Her goiter increasing gradually was known for more than 40 years. She was treated for hyperthyroidism for 5 years. Previously she refused to undergo surgery.
Palpation: both thyroids were enlarged, multiple nodules were palpated.
Functional state: subclinical hypothyroidism on daily 10 mg methimazole (TSH 6.09 mIU/L, FT4 12.0 pM/L, FT3 4.18 pM/L).
Ultrasonography: both thyroid were enlarged and consisted of multiple nodules with different echo patterns. The lower pole of the thyroids could not be visualized in supine position before swallowing. During swallowing, the lower pole of the right thyroid came into sight, while that of the left lobe remained obscure.
CT scan: demonstrated a minimal substernal spread in the right while a significant in the left thyroid.
Surgery was advised to the patient again. Surgery had to be extended with thoracotomy in the left side.
Histopathology: disclosed benign hyperplastic nodular goiter.
Comment. There are three degrees of substernal spread:
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Mild degree: the lower pole of the thyroid cannot be visualized uprightly but can be in supine position with extended neck. It is very common in elderly patients first of all of in men even in the absence of thyroid enlargement.
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Moderate degree: the lower pole cannot be visualized in supine position with extended neck before swallowing, but comes insight while swallowing. The goiter demonstrated in this case belongs to this category.
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Severe degree: the lower pole cannot be visualized in supine position with extended neck even while swallowing.