A 38-year-old woman from Mumbai presents with a 2-year history of progressive neck swelling and dysphagia. On examination, a firm, multinodular goitre is palpable with deviation of the trachea to the right. Thyroid function tests are normal (TSH 2.1 mIU/L). Fine-needle aspiration cytology (FNAC) of the largest nodule shows benign follicular cells. Contrast-enhanced CT neck reveals significant tracheal compression with narrowing of the airway lumen to 8 mm. What is the most appropriate management?

Explanation

## Clinical Assessment **Key Point:** Symptomatic goitre with significant tracheal compression (airway narrowing >50%) and dysphagia is an absolute indication for thyroidectomy, regardless of cytology or thyroid function. ### Indications for Thyroid Surgery in Benign Disease | Indication | Rationale | |---|---| | **Compressive symptoms** (dysphagia, dyspnoea, stridor) | Airway/oesophageal compromise requires definitive management | | **Tracheal compression >50%** | Risk of acute airway obstruction; surgery prevents emergency intubation | | **Cosmetic concern** (large visible goitre) | Acceptable indication in motivated patients | | **Hyperthyroidism uncontrolled by drugs** | Definitive treatment | | **Solitary nodule with malignancy risk** | Cytology-guided decision | **Clinical Pearl:** In this patient, the combination of: - Progressive dysphagia (compressive symptom) - Tracheal deviation and narrowing to 8 mm (objective compression) - Normal thyroid function (excludes medical management as primary option) - Benign FNAC (confirms low malignancy risk; does not negate surgical indication) All point to **total thyroidectomy** as the standard of care. ### Why Total vs. Hemithyroidectomy? **High-Yield:** Multinodular goitre with compressive symptoms is managed by **total thyroidectomy** because: 1. Both lobes contribute to compression in multinodular disease 2. Hemithyroidectomy leaves residual goitre tissue that may enlarge and recur (recurrence rate ~10–15%) 3. Intraoperative neuromonitoring is essential to monitor recurrent laryngeal nerve (RLN) function during dissection in a large, adherent gland ### Operative Considerations **Warning:** Do NOT use TSH suppression therapy as first-line in compressive goitre—it may slow growth but will not relieve existing mechanical obstruction. Suppression is reserved for small, asymptomatic nodules. **Mnemonic: COMPRESS** — Compressive symptoms warrant **Comprehensive thyroidectomy** - **C**ompressive symptoms present - **O**bstructive airway narrowing >50% - **M**ultinodular disease (both lobes involved) - **P**rogressive (worsening dysphagia over 2 years) - **R**ecurrent risk with partial resection - **E**ndocrine function normal (no medical alternative) - **S**urgery is definitive - **S**tandard approach is total thyroidectomy [cite:Sabiston Textbook of Surgery 21e Ch 37]