Goitre: Clinical Presentation, Diagnostic Evaluation, Surgical Management, and Outcome – A Case Report

Abstract

Goitre refers to the abnormal enlargement of the thyroid gland and remains one of the most common endocrine disorders worldwide. Although iodine deficiency remains a major cause globally, goitre may also develop due to autoimmune diseases, nodular thyroid disease, genetic predisposition, inflammatory conditions, and thyroid neoplasms. Patients may present with a visible neck swelling, compressive symptoms, cosmetic concerns, or thyroid dysfunction.

We present the case of a 45-year-old female who presented with progressive anterior neck swelling associated with difficulty swallowing and a sensation of neck fullness. Clinical examination revealed a diffuse thyroid enlargement. Thyroid function tests demonstrated euthyroid status, while ultrasonography identified a multinodular goitre. Fine-needle aspiration cytology excluded malignancy. Due to progressive compressive symptoms and cosmetic concerns, the patient underwent total thyroidectomy with an excellent postoperative outcome.

This case highlights the importance of comprehensive clinical assessment, appropriate imaging, cytological evaluation, and timely surgical intervention in the management of multinodular goitre.

Introduction

Goitre is defined as enlargement of the thyroid gland beyond its normal size. The thyroid gland plays a critical role in regulating metabolism, growth, and development through the secretion of thyroid hormones.

The causes of goitre are diverse and include:

• Iodine deficiency

• Multinodular thyroid disease

• Graves’ disease

• Hashimoto thyroiditis

• Thyroid adenoma

• Thyroid carcinoma

• Genetic and environmental factors

Goitre may be classified as:

• Diffuse goitre

• Nodular goitre

• Multinodular goitre

• Toxic goitre

• Non-toxic goitre

Although many patients remain asymptomatic, progressive enlargement may lead to dysphagia, dyspnea, hoarseness, and significant cosmetic concerns. Early diagnosis is important to identify underlying pathology and prevent complications.

Case Report

Patient History

A 45-year-old female presented to the outpatient department with complaints of:

• Progressive swelling in the front of the neck for 2 years

• Difficulty swallowing solid food for 3 months

• Sensation of pressure in the neck

• Mild discomfort while lying flat

The swelling had gradually increased in size over time.

The patient denied:

• Fever

• Weight loss

• Neck pain

• Palpitations

• Excessive sweating

• Tremors

There was no history of:

• Radiation exposure

• Thyroid surgery

• Family history of thyroid cancer

Past medical history was unremarkable.

Clinical Examination

General Examination

• Blood pressure: 128/82 mmHg

• Pulse rate: 78/min

• Respiratory rate: 18/min

• Temperature: Afebrile

• Oxygen saturation: 99% on room air

The patient appeared comfortable with no signs of thyrotoxicosis or hypothyroidism.

Local Examination

Inspection revealed:

• Diffuse enlargement of the anterior neck

• Symmetrical thyroid swelling

• Visible movement with deglutition

• No overlying skin changes

Palpation demonstrated:

• Enlarged thyroid gland involving both lobes

• Multiple palpable nodules

• Firm consistency

• Non-tender swelling

• No local warmth

No cervical lymphadenopathy was detected.

Pemberton’s sign was negative.

Clinical Evaluation

Differential Diagnosis

The following conditions were considered:

• Multinodular goitre

• Colloid goitre

• Thyroid adenoma

• Hashimoto thyroiditis

• Thyroid malignancy

• Graves’ disease

The gradual progression and multinodular nature of the swelling favored multinodular goitre.

Investigations

Laboratory Evaluation

Routine investigations revealed:

• Hemoglobin: 12.6 g/dL

• Total leukocyte count: 7,400/mm³

• Platelet count: 258,000/mm³

• Blood glucose: Normal

• Renal function tests: Normal

• Liver function tests: Normal

Thyroid Function Tests

Results demonstrated:

• TSH: 2.4 mIU/L

• Free T3: Normal

• Free T4: Normal

These findings confirmed euthyroid status.

Thyroid Ultrasonography

Ultrasound examination revealed:

• Enlarged thyroid gland

• Multiple bilateral thyroid nodules

• Largest nodule measuring 3.2 cm

• Mixed cystic and solid components

• Increased gland volume

• No suspicious cervical lymph nodes

Findings were suggestive of multinodular goitre.

Fine-Needle Aspiration Cytology

FNAC was performed from the dominant nodule.

Cytological findings revealed:

• Benign follicular cells

• Colloid-rich background

• No atypia

• No evidence of malignancy

Computed Tomography Scan

CT neck demonstrated:

• Enlarged multinodular thyroid gland

• Mild tracheal deviation

• No retrosternal extension

• Mild compression of surrounding structures

Diagnosis

Based on clinical examination, imaging, and cytological findings, a diagnosis of: Benign Multinodular Euthyroid Goitre with Compressive Symptoms was established.

Management and Outcome

Initial Management

The patient was counseled regarding available treatment options.

Management considerations included:

• Observation

• Thyroid hormone suppression therapy

• Radioiodine therapy

• Surgical intervention

Because of progressive enlargement, dysphagia, and tracheal deviation, surgery was recommended.

Surgical Management

The patient underwent:

Total Thyroidectomy

Intraoperative findings included:

• Enlarged multinodular thyroid gland

• No invasion of adjacent structures

• Preservation of recurrent laryngeal nerves

• Preservation of parathyroid glands

The surgery was completed without complications.

Histopathological Examination

Microscopic examination demonstrated:

• Multinodular hyperplasia

• Colloid-filled follicles

• No malignancy

The diagnosis of benign multinodular goitre was confirmed.

Postoperative Course

At 1 Week

• Minimal pain

• Normal wound healing

• No voice changes

• No hypocalcemia

At 1 Month

• Complete resolution of swallowing difficulty

• Excellent cosmetic outcome

• Stable thyroid hormone replacement therapy

At 6 Months

• No recurrence

• Normal quality of life

• Well-controlled thyroid hormone levels

Discussion

Pathophysiology

Goitre develops due to enlargement of thyroid follicular cells resulting from chronic stimulation of the gland.

Mechanisms include:

• Increased TSH stimulation

• Iodine deficiency

• Autoimmune activation

• Genetic susceptibility

• Growth factor-mediated cellular proliferation

Repeated cycles of stimulation and involution may lead to nodular transformation and multinodular goitre formation.

Epidemiology

Important epidemiological features include:

• More common in women

• Increased prevalence with age

• Higher incidence in iodine-deficient regions

• One of the most common endocrine disorders worldwide

• Significant healthcare burden in developing countries

Although iodine supplementation has reduced prevalence in many regions, multinodular goitre remains common.

Clinical Manifestations

Patients may present with:

• Neck swelling

• Cosmetic concerns

• Dysphagia

• Dyspnea

• Hoarseness

• Neck discomfort

Large goitres may produce compressive symptoms due to pressure on adjacent structures.

Some patients may develop:

• Hyperthyroidism

• Hypothyroidism

• Retrosternal extension

• Tracheal compression

Diagnostic Considerations

Diagnosis is based on:

1. Detailed clinical history
2. Physical examination
3. Thyroid function tests
4. Ultrasonography
5. Fine-needle aspiration cytology
6. Cross-sectional imaging when indicated

Ultrasonography remains the primary imaging modality for thyroid evaluation.

FNAC plays a critical role in excluding malignancy and guiding management decisions.

Treatment Modalities

Observation

Suitable for:

• Small asymptomatic goitres

• Stable thyroid nodules

Medical Therapy

May include:

• Thyroid hormone replacement

• Treatment of thyroid dysfunction

However, medical therapy has limited effectiveness in reducing large multinodular goitres.

Radioiodine Therapy

Useful in selected patients with:

• Toxic multinodular goitre

• Surgical contraindications

Surgical Intervention

Indications include:

• Compressive symptoms

• Cosmetic deformity

• Suspicion of malignancy

• Retrosternal extension

• Large goitre size

Total thyroidectomy provides definitive treatment in appropriately selected patients.

Complications

Potential complications of untreated goitre include:

• Airway compression

• Dysphagia

• Hyperthyroidism

• Hemorrhage into nodules

• Cosmetic disfigurement

• Rare malignant transformation

Early evaluation and treatment reduce the risk of these complications.

Prognosis

The prognosis depends upon:

• Underlying etiology

• Presence of malignancy

• Size of the gland

• Thyroid function status

• Timeliness of treatment

Most patients with benign multinodular goitre experience excellent outcomes following definitive treatment.

Conclusion

Goitre remains a common endocrine disorder with diverse etiologies and clinical presentations. Careful clinical assessment combined with thyroid function testing, ultrasonography, and cytological evaluation enables accurate diagnosis and appropriate treatment planning. This case demonstrates the successful management of benign multinodular goitre presenting with compressive symptoms through timely surgical intervention and postoperative thyroid hormone replacement. Early recognition, individualized treatment, and long-term follow-up remain essential for preventing complications and ensuring favorable patient outcomes.

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