Clinicopathological profile, airway management, and outcome in huge multinodular goiters: an institutional experience from an endemic goiter region.

BACKGROUND: Huge goiters are common in iodine-deficient endemic regions. They are of concern to the surgeons because of the anticipated risk of difficult dissection and increased chances of surgical complications. Similarly, they are of concern to the anesthesiologists because of anticipated intubation-related difficulties and post-thyroidectomy tracheomalacia. In the present study we aimed to present our experience of managing goiters based on their gross weight, highlighting their clinicopathological profile, perioperative airway-related difficulties, and management of surgical morbidity.

METHODS: Retrospective analysis of patients who underwent total thyroidectomy in the primary setting at our institute from 1995 to 2009 was carried out based on the gross gland weight. The patients were thus grouped into group A: ≤200 g; group B: 201 to ≤400 g; group C: 401 to ≤600 g; group D: >600 g.

RESULTS: Group A (660 cases); group B (108 cases); group C (36 cases); and group D (9 cases) were included. As the goiter size increased, the mean duration of goiter, compressive symptoms, retrosternal extension (RSE), airway deformity, intubation difficulty, and tracheomalacia increased. The rate of tracheostomy, sternotomy, hemorrhage, visceral injury, and hospital stay was high with huge goiters. These features were more marked in malignant goiters compared to benign goiters. However, the postoperative complications were comparable in both of those groups.

CONCLUSIONS: Long-standing huge goiters are common in iodine-deficient endemic areas. The majority of patients have symptomatic or clinicoradiological evidence of airway involvement. The incidence of RSE, airway deformity, intubation difficulty, and tracheomalacia is high with huge goiters. The surgery is technically demanding with greater associated chances of injury to native structures. Malignancy influences the presentation and outcome in smaller goiters. In centers with experienced endocrine surgeons and dedicated anesthetists, huge goiters can be successfully managed with minimal short-term and long-term morbidity.