Surgical Science , 2011, 2, 278-284
doi:10.4236/ss.2011.25060 Publish ed Onli ne July 2011 (http:// www.S ciRP.org/journal/ss)
Thyroidectomy for Massive Goiter Weighing more than
500 Gr ams. Tec hnic al Difficulties, Complications and
Man ag ement. Revi ew
Norman Oneil Mac hado
Department of Surgery, Sultan Qaboos Unive rsi ty Hospital,
Muscat, Oman
E-ma il: [e-mail]
Recei ved December 2, 2010; re vised April 4, 2011; acc epted May 31, 2011
A bs tract
Background: Multinodular goiter is a relatively common thyroid disorder with a marked female preponder-
ance. Most of these goit ers weigh less than 100 gr ams with thos e weighing more than 500 grams being ex-
ceptional. The massively expanding goiter du e to the str ategic anatomic l ocation of thyroid gland, in addition
to b ei ng c osmet i ca ll y di sfi guring ca n s er i ou sl y c o mp r o mis e t h e p a te nc y of t he t r a c hea a nd oes ophagu s. T hy-
roidectomy for such goiters is a surgical challenge due to the possible association of tracheomalacia, retros-
terna l ext ens ion, ski n in volv emen t a nd t he diffi cult y i n int ubation a nd diss ecti on o f th e thyr oid gla n d due to
distorted and displaced anatomy. Material and methods: While presenting 2 patients who underwent thyroi-
dectomy for glands weighing more than 500 grams, the literature is reviewed to analyze the technical diffi-
culties and approach in such patients and the frequently encountered complications in them and their man-
agement. Results: A review of the literature revealed an additional 7 cases of patients who had undergone
thyroidectomy for glands weighing more than 500 grams. Massively enlarged goiter was often associated
with tracheomalacia, tracheal stenosis and retrosternal extension. Difficulty during surgery was most often
encountered in establishi ng t he airway and in exposure of the gland particularly when the skin was involved.
The predominant postoperative complications were related to respiratory distress as a consequence of tra-
cheomalacia and tracheal stenosis. Conclus ion: In spite of the technical challenge related to the airway, and
thyroidectomy, surgery co ntinu es to b e t he b est opti on in exp erienc ed hands due to it s d ist inct a dva nt age of
its i mme d iate effect and complete resoluti on of compressive symptoms.
Keywords: Thyr oidec tomy, Mas sive Goiters, Tracheomalacia, Retro sterna l G oiter
1. Introduction
It is estimated that nodular goiter affects 5% of the gen-
eral population [1]. The usual goiter growth ratio is esti-
mated at 10 to 20% per year, though high individual va-
riability in the clinical course makes it difficult to predict
whether the goiter size will remain stable or whether dy-
namic thyroid growth will lead to its rapid progress war-
ranting surgical intervention [2]. Most of these goiters
are of modera te size bein g le s s than 100 gr a ms [3]. Gla n d s
weighing more than 500 grams are extremely unusual
and often result as a consequence of ignoran ce, neglect,
lack of inadequate medical facility, fear of undergoing
surgery or due to an unusually rapid growth as in malig-
nancy [4-7]. These patients pose a specific sur gical chal-
len ge and need to be managed by experienced surgeons.
In addition to presenting our exper ien ce wi th 2 cases, the
literature is reviewed to analyze the technical difficulties,
comp lication s an d the approach in managi ng t hem .
2. Case Repo rts
2.1. C ase 1
An 58 year old lady presented with a massivel y enlarged
goiter of more than 8years duration. She had recent his-
tory of exertional stridor and neck discomfort and had
declined surgery in the past out of fear of surgery. On
clinical examination the mass was measuring about 24 ×
18 cm s in vol vi n g m ost of th e n ec k (Figure 1). The lower

N. O. MACHADO ET AL.
279
bor der coul d n ot be felt . Th e compl et e bl ood pi c ture, and
thyroid function tests were within normal limits. A CT
scan revealed a massive goiter compressing the trachea
(Figure 2). After an informed consent the patient was
posted for total thyroidectomy. Flexible intubation was
performed. After adequate extension of the neck sup-
ported by sandbag, the neck was explored using a 30 cms
incision. After reflecting the subplatysmal skin flaps the
thyroid gland was exposed by dividing the strap muscles
as there was significant compression of internal jugular
vein and carotid vessels and distortion and displacement
Figure 1. Massive goiter weighing more than 800 grams
involvi ng most of the neck.
Figure 2. CT scan—transverse section revealing significant
compression and deviation to the right of trachea by the
massively enlarged goiter.
of these structures. The superior pedicle, multiple dilated
middle thyroid veins and inferior thyroid vein and
branches of inferior thyroid artery were carefully ligated
on both sides. The recurrent laryngeal nerve and para-
thyr oi ds were i d entifi ed on both sid es and preserved. The
r etr ost erna l ext ension of the goiter was delivered into the
neck by gentle finger dissection and upward traction in
the subcapsular plane. The total blood loss was 180 mL.
The tracheal cartilage appeared healthy and the patient
was extubated on Table immediately after the surgery.
There were no postoperative complications and the pa-
tient was discharged on the 4th postoperative day. The his-
topathology was reported to be multinodular goiter, the
total weight of the excised gland being 824 grams. (See
Figure 3)
2.2. C ase 2
A 62 year old lady who was clinically euthyroid pre-
sented with progressively enlarging goiter of 10 years
duration. The g oiter mea su red 20 × 16 and prominent veins
in the neck and chest were observed due to retrosternal
extension (Figure 4). The complete blood picture and
thyroid function tests were within normal limits. CT scan
of the neck revealed tracheal compression and retr oster-
nal extension. The patient was posted for total thyroi-
dectomy after an informed consent. The intubation was
achieved by direct laryngoscopy. Adequate exposure of
th e thyroid glan d was achieved by suffici ent neck ext en-
sion, division of strap muscles and adequate retraction.
After ligating all the vessels carefully and identifying
and preserving the recurrent laryngeal nerve and para-
thyroids on both sides, the retrosternal extension of the
goiter was delivered into the neck by gentle finger dis-
section and traction. The total blood loss was 130 mL
and the patient was extubated on Table at completion of
the surgery. The postoperative period was uneventful.
Fi gure 3. Post total thyroidectomy speci men revealing gland
weigh ing 824 gram s .

N. O. MACHADO ET AL.
280
Figure 4. Patient 2—with massively enlarged goiter with
retrosternal extension revealing associated dilated jugular
and anterior chest veins.
The excised gland weighed 640 grams and was reported
t o be a mul t i nodu lar benign goit er .
3. Di sc u ssi o n
Thyroidectomy for massively enlarged goiter could be
technically challenging particularly when they are more
than 500 grams. The specific problems associated with
them are difficulty in securing airway, adequate exposure,
blood loss, and potential risk of injury to recurrent la-
ryngeal nerve, oesopha gus and the parath yroid glan d due
to distorted and displaced anatomy [4-9]. Moreover there
is an increased possible association of tracheomalacia,
tracheal compression, retrosternal extension and skin
complications due to ulceration or infiltration by the
ma ssi vel y enlar g ed goit er [4-9]. The s urg ical ap proach to
such cases requires careful preoperative evaluation and
planning. Each case is dealt with differently and the
technical difficulties both surgical and anaesthetic must
be anticipated in order to minimize perioperative mor-
bidity and mor tality,
Intubation of these pati en ts coul d be dem and in g due to
gross tracheal deviation, compression or tracheomalacia
and should be anticipated by the anaesthetists in the
preanaesthetic assessment [4,6,8-10]. Intubation is
usually achieved in these difficult cases by flexible intu-
bation using relatively smaller sized tube (size 4 and
above) in case of severe narrowing [4,6,7] (Tables 1 &
2). Awake intubation using fiberoptics and local anaes-
thetics has been performed successfully in extremely
difficult cases [4, 6,8 ]. An oth er di fficult situation is when
the st enosis is over a l ong s eg ment. Succes sful intu bation
has been achieved in patients with stenosis extending
from the cricoid cartilage to carina by passing an ex-
tended length tube (Sheridan, 4 mm—internal diame-
ter-endotracheal tube-Hudson RCI USA, Temecula,CA)
through the ste- nosis with the tip at the level of carina
[8]. Massively enlarged goiter have also been removed
succ ess ful l y un der l ocal ana esth es ia ( LA), an excep ti ona l
case being the removal of a thyroid gland weighing 1.9
kg [5]. The merits of performing thyroidectomy under
LA a ccordi n g t o th e a uth our is specially in a rural setting
in a developing country where there is frequent shortage
of equipment, drugs, trained theater personnel and ward
staff [5]. The severe shortage of staff in such countries
means th at it is n ot sa fe to h ave a pa ti ent recovering from
GA unsupervised after an operation on the neck [5].
Surgery under LA made it feasible to send these patients
immediately back to ward fully conscious and able to
communicate [5]. However the obvious risk of perform-
ing difficult thyroidectomy under LA is an unforeseen
situation of severe bleeding or respiratory distress leav-
ing the pati e nt and s urgeon in a vulne ra ble positi on.
Thyroidectomy for a massively enlarged goiter re-
qu ir es the n eck to be well ex posed b y ad equat e ext ension
achieved by placing adequate amount of sandbags under
the shoulder [4,7,8]. The incision is invariably long ex-
tendin g even u p to 40 cm s at tim es [7]. In patients where
skin is involved with resulting ulceration as in a malig-
nant goiter, the skin incision will have to be fashioned t o
in cl ude an d ex cise th e u l cera ted ar ea [ 4] . After refl ecti ng
the subplatysma skin flap adequate exposure is achieved
by dividing the strap muscles and if need be the sterno-
mastoid muscle [4,7,8]. This ensures safe ligation of the
superior pedicle, the middle thyr oid vein and br anches of
inferior thyroid artery. Securing these vessels in this
crowded space could be demanding as the internal jugu-
lar vein and carotid artery are compressed and displaced
by the massively enlarged goiter. The use of harmonic
scalpel may facilitate safe and speedy securing of these
vessels specially when they are multiple and dilated due
to partly obstr ucted venous outflow as in the pr esence of
retrosternal extension [7]. Of particular concern is also
the pot e nt ial r is k of inj ury to the oesophagu s du e to gros s
distortion of the anatomy in patients with retropharyn-
geal and retroesophageal extension and preoperative in-
sertion of nasogastric tube may serve as a guide to iden-
tify it [7,10]. The removal of the gland may be facilitated
by dividing it at the isthmus after mobilizing one lobe
rather than attempting to remove it in toto [7]. The re-
m ova l of t he oth er h al f wou ld then be r el a ti vely eas y du e
to the space created. Care is taken to preserve the para-
thyroids and prevent injury to the recurrent laryngeal
nerve [3-10]. Use of intraoperative nerve mon itoring has
been reported to be very useful in these difficult cases
[11]. Apart from facilitat ing n avi gation thr ough di stort ed
anatomy it may lend itself as a routine adjunct to the gold

N. O. MACHADO ET AL.
281
standard of visual nerve iden tification [11].
Three sp ecific p robl em s that are lik ely to be ass ociated
with massively enlarged goiter is that of skin involve-
ment, tr a ch eomal aci a and r etr ost erna l ext en si on [4, 6-10].
In one of the reports with extensive involvement of skin
two approaches have been employed4. In one approach
for a patient with a fungating lesion the dissection was
initially carried out from the noninvolved side [4]. This
allowed access to the goiter on the involved side from
within, gradually dissecting the en tire mass together with
excision of the overlying skin elliptically ar ound it [4]. In
an oth er patient with an ul cerated bl eedin g lesi on the lin e
of i ncision includ ed the entire ulcera ted area init iall y an d
th en deepen ed t o li ft th e skin flaps at th e onset. Th e th y-
roid lobe was then mobilised from the involved side pro-
gressing on to the side where skin was not involved [4].
The wide excision of the in volved skin poses a pr oblem
in skin cl osure. Whil e a small segm ent of the defect could
be closed by m obilizing the adjoining skin, larger defects
particularly in a previously irradiated skin may require
closure by mobilizing flaps like a deltopectoral flap [4].
Tracheomalacia is an uncommon complication in a
patient undergoing thyroidectomy and occurs in 0.1 to
0.5% [12]. However in patients with massively enlarged
goiter the risk is relatively higher [7,12]. The major con-
cern is that it may cause life threatening post operative
airway obstruction with the recorded mortality of 44%
[12,13]. Its mechanical effect usually results from com-
pression by the surrounding goiter l eadin g to softening of
the tracheal cartilage [12,13]. The trachea may collapse
immediately following extubation or as late as 48 hours
in t o the p ostopera ti ve per i od. S evera l t echn iq ue for iden-
tifying tracheomalacia have been advocated [14-17]. A
simple and economical method of detecting tracheoma-
laci a on the op er ating table is at the en d of su rgery before
reversing residual neuromuscular blockade and extuba-
tion [14]. After thorough suctioning of the oropharynx,
the cuff is deflated [14]. Tracheomalacia would result in
tracheal collapse over the tube preventing peritubal leak
after cuff deflation [14]. The presence of leak would ex-
clu de tr ach eal coll aps e [14 ]. Intra-oper at ive in sp ecti on of
the trachea by the surgeon also may reveal tracheomala-
cia [7]. In such a situation in addition to surgical
re-enforcement, the patient may need to be intubated in
early postopera t ive period.
In patients at risk of developing upper airway obstruc-
tion following thyroidectomy the choice lies between
prophylactic endotracheal intubation and tracheostomy
[13,17]. Endotracheal intubation is favoured by many
due to its less morbidity [13]. However tracheostomy
may be needed in situation wer e the trachea collapse s post
tumour r emoval [7]. Tracheostom y h as been r eported to
ha ve been p er form ed in 6% (59/ 964) of pati ent s foll owing
thyr oidectomies [18], th e indication primaril y being intra-
operative tracheal deformity with narrowing (more than
50%) of tracheal circumference on radiology and gland
adherence to the tracheal wall or tracheomalacia [12,18].
A massively enlarged goiter is often associated with
me di as tina l ext en si on givi n g r i se to a dd it i on a l ch allenges
to the surgeon [7,10]. These include difficult intubation,
incision and approach to the tumour, tracheomalacia ,
pos sibil it y of st ern otom y an d pr oblem of woun d h ealing.
However, majority of the retrosternal goiters are second-
ary, having extended from the neck into the superior me-
diastinum. These can be removed by transcervical ap-
proach by finger dissection and upward traction of the
cervical thyroid through the subcapsular plane after se-
curing its blood supply initially in the neck [7,8,10,19].
Extracervical approach like median sternotomy or lateral
thor ocotom y is reserved for cases with pr evious cervical
th yr oidect om y, invasive car cinoma, ect opi c primar y goi-
ter and goiter extending into the posterior mediastinum
wel l beyon d th e a ort ic arch and ma y n eed t h e services of
cardiothoraci c s urg e ons [19 ].
Patients with large goiters may functionally be hypo-
thyroid, hyperthyroid or euthyroid. The commonly en-
countered symptoms in patients with massively enlarged
goiters are dysphagia and dypsnea due to oesophageal
and tracheal compression [3,4,7,9,10]. These lesions
coul d be ben i gn or mal i gnan t and th e path ol ogi cal natur e
of the goiter is established by fine needle aspiration cy-
tology .Computerized tomography scan is an useful im-
aging modality especially in complicated massive goiter,
in delineating the degree of tracheal compression and
deviation and establishing the extent of retrosternal ex-
tension [7,10,19]. Most of these patients with massively
enlarged g oi ters ar e man aged b y to tal thy roide c to my [20].
Tot al th yr oid ect om y is pr efer r ed as 10 to 20% r ecurr en ce
has been observed in patients with lesser surgery [20]. In
such patients postoperative thyroxine may fail to pr event
recurrence suggesting the glands are becoming increa-
singly autonomous during growth [20]. Moreover sur-
gery for recurrent goiter carries a 10 fold higher compli-
cation rate with complications such as permanent hypo-
parathyroidism (3.4%) and recurrent laryngeal nerve
pal sy (8%) [3,20]. However most authours conclude th at
surgery is the best management strategy in generally
health y patien ts with large goiters [3,4-9]. The most im-
portant advantage of thyroid surgery for massively en-
larged goiter being its immediate effect and complete
resolution of obstructive symptoms [3,4-9].
4. Literature Revi ew
A medline literature search of English language articles
was performed using terms massively enlarged goiter or

N. O. MACHADO ET AL.
282
large goiter. All articles that reported thyroidectomy for
goiters weighing more than 500grams were reviewed
including those that were discovered in references in the
article uncovered during the search. The studies with
incomplete data particularly in relation to the weight
were rejected. Since 1970 a total of 7 cases of patients
un der goin g th yr oidect om y for glan ds weighin g in excess
of 500 grams were identified [4-9]. Interestingly all the
patients in cluding the 2 in our study were female patients.
The demographic details and presentation are noted in
Table 1. Tracheal compression was seen in 2 patients
and tracheoma laci a and tra ch ea l sten osis was seen in one
patient each. Skin involvement was seen in 2 patients
(fungating lesion and large bleeding ulcer) both related
to underlying thyroid malignancy (papillary carcinoma
and medullary carcinoma of thyroid) (Table 1). The in-
tubation was achieved by direct laryngoscopy (4 pa-
tients), flexible intubation (3 patients), awake intubation
(1 patient) and one patient underwent thyroidectomy
under local anaesthesia. The maximum length of the in-
cision was 40 cms (range 28 to 40 cms in cases were it
was mentioned) (Table 2). In 2 patients where the skin
Ta bl e 1. Literature Review—Thyr oid ec tomy for gl an ds weigh ing m ore tha n 500 grams Demographic details/clinical f eatures.
Author-y ear
No o f
pt s Age yrs Se x M: F
Size of
gland cms
Weig ht of
gla nd gms Symp Retrost Exten
Tracheal
deform ity Sk in I nv.
T hyr oid
path olo gy
Present 2 58 0:1 24 × 18 824 Dys/Ndis 1 cm T com Nil MNG
study 62 0:1 20 × 16 640 Dys/ Nd is 2 cms Tcom Nil MN G
Irfan
et al7
2010 1 30 0:1 30 × 15 915 Dys Dysph toxi c +Upto AA T mal-1 Size -6mm no Colloid go it er
Dere K6
2008 1 19 0:1 36 × 15 1235 cretin no no no MNG
Eloy JA8
2007 1 46 0:1 20 × 9 610 Dys Dysph +u pt o carina Tst en > 90% no MNG
Harjit K4
2005 2 52 66 0:2 14 × 7 19 × 25 ? 1100
Previous
Thyrect + RT
(2pts) no no fungating
u l cerati ng Papillary ca Medulla ry ca
Hodges AM5
2005
1 30 0:1 ? 1900
Pain
Ndis
no no no MNG
Holde n M P
et al 9 1972 1 38 0:1 ? 800 Hyp ert ension -comp A A
Pre vious Th y rect + Upto AA no no Colloid go it er
T ot a l 9 (30 - 66)
Mean-44.5 0:9 36 × 25
(640 ×
1900)
Mean-823
Pain/Nd is-3
Dys-4
Dysph-2 5
Tcom-2
Tsten-1
Tmal -1 2 Be nign -7
Malignant -2
Rt Ext—retrosternal extension, Dys—dysnea or stridor, Dysph—dysphagia, Ndis—neck discomfort, AA—arch of aorta, Tcom—tracheal compression,
T sten—tracheal st enosis, Tmal—tracheomalacia, thyre ct—thyroi dectom y
Ta bl e 2. Literature review—su rgical det a i ls .
Author-y ear Int ubation T e chnique
T ube size incision Division of St p or Sm Use of ha r m o n ic scalpel Blood loss Complications
Present study (2pts )
2010
Fl ex Int
Flex int
36 c m s
30 c m s
Stp - yes
Stp - yes
No
No
180
130
nil
nil
Irfan
et al7
(2pts)
2010 Flex.int 6.5 mm 40 cms ? Stp - yes Sm -no + ? T r a che o st o my for Tmal
Dere K6
2008
DL
5.5 mm
? no no ? nil
Eloy JA8
2007
DL
4mm She ridan tube ? no no ? nil
Harjit K4
2005 Aw int Elliptical + Skin excision no no ? nil
Hodges AM5
2005
LA
0.25% l ignoci ane -
Adren al in e -1: 200,000
Pet hedine
ketam ine
lo ng ? ? ? Oedema of sk in flap
Holde n M et al 9
1972
DL
Right
T hor ocotomy-6
th
rib
-- no ?
Urinary tract
infe ction
T ot a l
GA-8
LA-1
DL-4
F lex int-3
Aw i nt-1
T hor ocotomy-1
Ne ck inc ision-8 Stp - 3 Sm-1 H a r m onic scal- pel-1
(130 - 180 ml)
Most have not
re ported T racheostomy-1
Fl ex int—flexible intubation, DL—d irect laryngoscopy, Aw int—awake intubation, S tp—st r ap musc les, Sm—ste rnomastoid muscle.

N. O. MACHADO ET AL.
283
was i n vol ved a n d re qui r ed ex ci si on of i n vol v ed seg m en t ,
the skin cover after thyroidectomy was achieved with
local advancement flap or deltopectoral flap in one pa-
ti en t each . Th e goi ter s were of a ben ign na tur e except for
2 cases with malignancy. The mean weight of the gland
that was excised was 823 grams (range 640 - 1900 gr am s ).
Thyroidectomy was facilitated by the use of harmonic
scalpel, division of strap muscles and sternomastoid
mu scl e in som e of th ese p ati ent s (Table 2). Fou r of these
patients had retrosternal extension, 3 of them being ap-
proached transcervically and one with previous thyroi-
dectomy was approached through right lateral thorocot-
omy. Tracheostomy had to be performed in one patient
with severe tracheomalacia who was initially managed
with intubation but failed following extubation; in two
other patients tracheostomy was performed because they
required prolonged period of postoperative intubation.
Interestingly complication s including recurrent laryngeal
nerve palsy, hypocalcaemia or postoperative haemorr-
hage was not reported in an y pa tients probably reflecting
the special care taken in performing these challenging
cas es b y exper ienced s urgeons.
5. Conclusions
Thyroidect omy for a massively enlarged goiter especial-
ly when weighing more than 500 grams is technically
challenging. Airway management, integrity of adjacent
structures as well as anticipating the possible complica-
tions should be considered as high priority. Often asso-
ciated findings in these patients include tracheal com-
pression and tracheomalacia, retrosternal extension, and
possible skin involv ement. In spite of the techn ical ch al-
lenge, surgery con tinues to be the be s t opt ion particularly
in experienced hands due to its distinct advantage of
immedi ate effect an d complete resolution of compressive
symptoms.
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