Thyroid swelling forms one of the most important differentials for swelling in front of the neck. The differential diagnoses of thyroid swelling are benign goitre, intrathyroid cysts, thyroditis benign and malignant tumours.

•           Simple goitre is enlarged thyroid gland and occurs commonly around puberty in girls iodine deficiency.

•           Malignancy should be suspected in case of extremes of age, male sex, rapidly growing swelling, persisting pain, dysphagia, recurrent laryngeal nerve palsy, hardness and fixity of the gland and presence of one or more palpable neck nodes.

•           Thyroid function test, Fine needle aspiration cytology, ultrasonography are helpful in differentiating the causes of thyroid swelling.

Treatment

1.            Simple diffuse hyperplastic goitre is preventable by using iodized salt.

2.            Treatment with L-thyroxine may reverse the swelling at this stage. Simple nodular goiter is treated by subtotal thyroidectomy

3.            Thyroidectomy

Preoperative care - Indirect laryngoscopy (IDL) is performed to identify compensated or unsuspected recurrent laryngeal nerve palsy. Before operation, thyrotoxic patients should be made euthyroid with antithyroid drugs (carbimazole 10-15 mg 4 times a day and prop 20 mg 3 times a day). Fully discuss the potential complications with the patients- mentioning risk to parathyroid gland and recurrent laryngeal nerve.

Postoperative care - Place patient in a slightly propped up position. Carefully observe for respiratory insufficiency, haemorrhage from the wound, irritability to the facial nerve and carpopedal spasm (parathyroid injury). Monitor drain output daily and remove if 24 output becomes lesser than 10 ml. Check wound site for infection and sutures are removed on the 5th day.

Complications

•        The most immediate life-threatening complication is haemorrhage under deep cervical fascia which can lead to acute asphyxia. Management includes reopening of the suture line, to drainage of the hematoma and re-exploration for control of bleeders.

•           Damage to recurrent laryngeal nerve can lead to respiratory distress (bilateral recurrent laryngeal nerve) and hoarseness of voice.

•           Parathyroid damage leads to hypocalcaemia. Symptomatic hypocalcaemia (positive Chvostek's or Trousseau's signs or corrected serum calcium level <8 g/dl) is treated with 10% calcium gluconate intravenously. If hypocalcaemia persists, oral Calcium supplement and synthetic Vitamin D is necessary.

•           Late complications include recurrent thyrotoxicosis, hypothyroidism, and recurrence of malignancy at the local site or in the lymph nodes in the neck.

4.  Radio-iodine therapy

•           Radio-iodine therapy is indicated in follicular, papillary and mixed carcinoma.

•           Following total thyroidectomy; a total body radioactive isotope scan should be arranged four weeks after the operation.

•           During this period L-thyroxine therapy should be withheld.

•           If radioactive scan shows residual thyroid tissue or metastatic deposit then further dose of radioiodine should be given to ablate these.

•           Following isotope scan, high dose L-thyroxin (0.2-0.3 mg) should be started and continued for life.

•           Radioactive iodine has no role in residual/metastatic medullary carcinoma.

•           Treatment approach to Hurthle cell neoplasm is similar to follicular neoplasm.

5.  Follow up

Patients should be followed at three monthly intervals for the initial 2 years and 6 monthly for three years and then at yearly interval for life.

On each follow up visit patient should be examined for any local or nodal recurrence in the neck, a chest X-ray should be done to exclude pulmonary deposit and clinical features of thyroid toxicity noted and dose of L-thyroxine regulated