A 38-year-old woman from Mumbai presents with a 2-year history of progressive swelling of the thyroid gland. She reports difficulty swallowing solids and occasional stridor at night. On examination, the thyroid is firm, multinodular, and extends retrosternally. TSH is 2.1 mIU/L (normal), and fine-needle aspiration cytology (FNAC) shows benign colloid nodules. CT chest shows significant compression of the trachea with deviation. She is euthyroid and has no family history of thyroid cancer. What is the most appropriate management?

Explanation

## Clinical Scenario Analysis This patient has a **benign multinodular goiter with significant airway compression** — a clear surgical indication despite euthyroid status and benign cytology. ### Key Indications for Thyroid Surgery in Benign Disease | Indication | Rationale | This Case? | |---|---|---| | **Airway/esophageal compression** | Symptomatic stridor, dysphagia, retrosternal extension | ✓ Present | | **Cosmetic concern** | Visible swelling affecting QoL | Possible | | **Hyperthyroidism uncontrolled** | Graves' disease, toxic multinodular goiter | ✗ Euthyroid | | **Rapid growth** | Suggests malignancy risk | ✗ 2-year indolent course | | **Benign cytology + euthyroid** | Observation often safe | ✗ Overridden by compression | **Key Point:** Symptomatic compression (stridor, dysphagia, retrosternal extension) is an **absolute indication for surgery** in benign thyroid disease, regardless of TSH or FNAC results. ### Why Total Thyroidectomy? 1. **Retrosternal extension** — requires complete removal to prevent recurrence and residual compression 2. **Multinodular disease** — high recurrence risk with subtotal approach (10–15% vs. 0–5% with total) 3. **Euthyroid status** — no need to preserve thyroid function; lifelong levothyroxine replacement is acceptable and preferred 4. **Modern safety** — recurrent laryngeal nerve (RLN) injury rate < 1% in experienced hands; permanent hypoparathyroidism < 0.5% with careful identification of parathyroid glands **Clinical Pearl:** In benign multinodular goiter with compression, total thyroidectomy offers the lowest recurrence rate and definitive symptom relief. The patient accepts lifelong levothyroxine replacement as a trade-off. **High-Yield:** Compression symptoms (stridor, dysphagia, SVC syndrome) override conservative management — surgery is indicated even in euthyroid, benign-cytology cases. ### Operative Considerations - **Preoperative laryngoscopy** — assess vocal cord mobility and rule out RLN involvement - **Intraoperative neuromonitoring** — recommended to reduce RLN injury risk - **Careful parathyroid identification and preservation** — critical to prevent hypoparathyroidism - **Postoperative levothyroxine** — start at 1.6 µg/kg/day; titrate to TSH 0.5–2.0 mIU/L [cite:Sabiston Textbook of Surgery 21e Ch 38]