A 54-year-old Indian female comes to your office because of dysphagia. She emigrated from India two years ago. She is the mother of a computer engineer, and lived her whole life in an iodine-deficient area in India. She denies any past medical problems, and is currently on no medications. For the past five months, she has been having some difficulty in swallowing large chunks of food, which seems to be progressively getting worse. She has no difficulty in breathing or swallowing liquids. Her weight is constant. She denies fever, cough, chest pain, abdominal pain, heat intolerance, sweating, or tremors. She is a vegetarian, and does not smoke or drink. She has never undergone any mammography or Pap smear screening. Her last menstrual period was four years ago. She has minimal hot flashes, and was never on hormone replacement therapy. Her family history is significant for a father with type-2 diabetes mellitus. Examination of her neck reveals a short neck with a very low lying thyroid; its lower margin could not be felt. The upper one-third of the sternum is dull on percussion. Her face becomes plethoric after raising her arms for one minute. There is no lymphadenopathy. The rest of the physical examination is normal. TSH is 0.78 μU/mL (normal 0.35-5.0 μU/ml), free T4 is 1.3 μU/ml (normal 0.8-1.8 μU/dl), and antithyroid peroxidase antibody is negative. Chest x-rays reveal a large upper mediastinal mass that is shifting the trachea to the left side. A CT scan of the chest reveals that the upper retrosternal mass is consistent with a large multinodular retrosternal thyroid gland. A barium swallow shows mild compression of the esophagus by the goiter. What is the best option for the management of this patient?

Question

A 54-year-old Indian female comes to your office because of dysphagia. She emigrated from India two years ago. She is the mother of a computer engineer, and lived her whole life in an iodine-deficient area in India. She denies any past medical problems, and is currently on no medications. For the past five months, she has been having some difficulty in swallowing large chunks of food, which seems to be progressively getting worse. She has no difficulty in breathing or swallowing liquids. Her weight is constant. She denies fever, cough, chest pain, abdominal pain, heat intolerance, sweating, or tremors. She is a vegetarian, and does not smoke or drink. She has never undergone any mammography or Pap smear screening. Her last menstrual period was four years ago. She has minimal hot flashes, and was never on hormone replacement therapy. Her family history is significant for a father with type-2 diabetes mellitus. Examination of her neck reveals a short neck with a very low lying thyroid; its lower margin could not be felt. The upper one-third of the sternum is dull on percussion. Her face becomes plethoric after raising her arms for one minute. There is no lymphadenopathy. The rest of the physical examination is normal. TSH is 0.78 μU/mL (normal 0.35-5.0 μU/ml), free T4 is 1.3 μU/ml (normal 0.8-1.8 μU/dl), and antithyroid peroxidase antibody is negative. Chest x-rays reveal a large upper mediastinal mass that is shifting the trachea to the left side. A CT scan of the chest reveals that the upper retrosternal mass is consistent with a large multinodular retrosternal thyroid gland. A barium swallow shows mild compression of the esophagus by the goiter. What is the best option for the  management of this patient?

Quizplus · Accepted Answer

Explanation: The patient has a large retrosternal goiter that is causing compressive symptoms. Surgical removal (preferably via cervical approach) is recommended. The goiter is probably due to iodine deficiency. Such goiters are usually multinodular. The thyroid has enlarged preferentially in the patient's thorax due to her short neck. (Choice D) The patient is euthyroid. Antithyroid drugs are not indicated. Antithyroid drugs (PTU and methimazole) may even lead to a slight enlargement of the thyroid, and are therefore not preferred over surgery in patients with retrosternal goiters and compressive symptoms. (Choice C) Radioactive radioiodine ablation can also result in some enlargement of the thyroid, which can increase the compressive symptoms. (Choice B)External beam radiation has no role in the treatment of retrosternal goiter. (Choice E)Levothyroxine may be used in the treatment of multinodular goiters; however, results are usually unsatisfactory. Full resolution of the goiter is uncommon. Furthermore, longstanding multinodular goiters usually have fibrosis and degenerative changes, and are unlikely to respond to levothyroxine. Levothyroxine can potentially lead to thyrotoxicosis, and increases the risks for bone loss and atrial fibrillation. Educational Objective: Management of retrosternal goiter with compressive symptoms is surgical.

A 54-Year-Old Indian Female Comes to Your Office Because of Dysphagia