The common surgical problem with the thyroid is a painless increase in its size, or the appearance in it of a painless mass. A painful thyroid is either due to haemorrhage (not uncommon in colloid goitre or carcinoma), or an abscess (rare in the developed world, and seen infrequently here, 5.10a). When a goitre or a mass needs surgery, the patient usually needs subtotal or total removal of his thyroid. This is not easy, and we have already given our reasons why you should refer the patients who need this done (21.1). There are however some ways in which you can help patients with surgical diseases of their thyroids.
GENERAL METHOD [s8]FOR THE THYROID DIAGNOSIS. Note the patient's age, his (or more often her) sex, and where he lives. Simple and colloid goitres are common in females in the second and third decades, and in anyone who lives in an iodine-deficient area. How long has it been present? Has there been a sudden increase in the size of the mass in his neck? Is it painful? Does he have difficulty breathing or swallowing?
Inspect his neck from in front, and feel it from in front and from behind. Give him a drink, and confirm that it moves up when he swallows (all thyroid swellings do this). Feel the size of its lobes and its isthmus; feel its surface and consistency, and listen for a bruit.
IS HE HYPERTHYROID? You can diagnose moderate and severe thyrotoxicosis clinically. Minor degrees require measurement of his basal metabolism and/or hormone assays.
Suggesting hyperthyroidism: Loss of weight? Tremor, especially of his outstretched arms and fingers? Sweating? Anxiety? Hyperactivity? Exophthalmos? Lid lag (his upper lid is slow to follow his globe when he looks downwards)? Palpitations? Tachycardia? Cardiac irregularities (flutter, fibrillation)? Heart failure? His thyroid is usually enlarged, and may or may not be nodular. You can often hear a bruit.
SUDDEN ENLARGEMENT [s7]OF THE THYROID GLAND In order of frequency the causes are: (1) Bleeding into the cyst of a colloid goitre. This will make it painful initially, but the pain may have gone by the time he presents. (2) Increase in the size of the colloid cysts of a goitre (this is not really sudden). (3) Bleeding into a carcinoma. (4) A rapidly growing carcinoma. (5) Acute bacterial infection (5.10a).
Refer him urgently. If dyspnoea is present, aspirate the haematoma or the abscess. If this does not relieve him (unusual) try tracheal intubation (A 13.2) or tracheostomy (52.2, difficult).
A SOLITARY NODULE [s7]IN THE THYROID If he presents with a solitary nodule, first confirm that it is in his thyroid, and then feel carefully for other nodules.
If there are other nodules he probably has a nodular colloid goitre, and he may perhaps be thyrotoxic (unusual).
If it really is a solitary nodule, it is quite likely to be a papillary carcinoma (which has a good prognosis with radical surgery), or a follicular carcinoma (with a worse one). Refer him to an expert, who will explore his neck and do a subtotal, hemi- or total thyroidectomy, as required.
If you have a quick and reliable histology service, consider needle biopsy. Even a good pathologist may have difficulty distinguishing normal thyroid tissue from a low-grade papillary carcinoma. He will however be able to recognize the nodule of a colloid goitre.
CAUTION ! (1) Enucleation is easy, but is not satisfactory because: (a) It does not remove a carcinoma completely. This is particularly important if it is papillary. (b) He may think he is cured, and not report back for radical surgery. (c) It makes a second operation more difficult. (2) Don't explore a solitary nodule unless you can do a thyroidectomy.
If he is unable or unwilling to be referred, follow him up regularly, and measure the nodule. If it enlarges try to persuade him again to be seen by an expert.
DON'T TRY TO EXCISE A SOLITARY THYROID NODULE UNLESS YOU CAN DO A THYROIDECTOMY Fig. 21-13 SOME LESIONS OF THE THYROID. A, a patient with a non-toxic adenomatous mass in her thyroid gland. B, the mass removed at thyroidectomy. C, the smooth, soft, symmetrical goitre of puberty or pregnancy. D, the large, smooth firm symmetrical swelling of a colloid goitre, thyrotoxicosis, or Hashimoto's disease. E, a large, nodular, firm, assymetrical goitre. F, the solitary nodule of an adenoma, carcinoma, or cyst. G, congenital abnormalities of thyroid development.
1, the foramen caecum. 2, 3, and 4, positions for thyroglossal cysts. 5, the pyramidal lobe. 6, a mediastinal goitre. 7, the hyoid bone. 8, the thyroid cartilage. A, and B, after Bowessman, Charles, ''Surgery and Clinical Pathology in the Tropics,' E and S Livingstone, with kind permission.