A total of 2,034 subjects aged 15 years and above from different parts of the State of Kelantan were studied to determine goiter size and urinary iodine excretion. The State was divided into 2 areas - area 1 consisting of localities in the districts near the coast and area 2 consisting of localities in the inland districts. There were 1,050 subjects in area 1 and 984 subjects in areas 2. The mean age (+/- SE) of subjects in areas 1 and 2 were 38.2 + 0.5 and 37.1 +/- 0.5 years, respectively. The prevalence of goiter was 31.4% in area 1 and 45.0% in area 2; the difference was statistically significant (p < 0.05). However, the prevalence of large and visible goiters (grades II and III) was only 2.0% in area 1 and 3.3% in area 2; the difference was not statistically significant. The mean (+/- SD) urinary iodine excretion in areas 1 and 2 was 57.1 +/- 2.1 and 56.8 +/- 2.1 micrograms I/g Cr, respectively. The values were below those recommended by WHO. There was no significant difference in urinary iodine excretion between those with and without goiters in both areas and also between the grades of goiters. There were significantly more females with goiters than males in both areas but there was no significant difference in the urinary iodine excretion between the 2 sexes. Thus based on urinary iodine excretion, the iodine intake of the population in this area, was suboptimal and this was associated with a high prevalence of goiter.
In a survey of 974 villagers (408 males, 566 females; ages = 11-82 years) of the Ai (n = 496; 212 males, 284 females) and Lemanak (n = 478; 196 males, 282 females) rivers in the district of Lubuk Antu in Sarawak's Sri Aman Division during July 1993, goiter was found in 31.8% of the subjects. The goiter prevalence was higher in the more interior Ai river area than in the Lemanak river area (36.9% vs 26.5%). In females aged 15 years and above, the goiter prevalence was 75.4% and 49.1%, respectively, in the Ai and Lemanak river areas. The difference in goiter prevalence between the two areas was related to the degree of iodine deficiency in the two areas. The median urinary iodine excretion in the Ai river villagers was 22.1 micrograms/l compared to 72.9 micrograms/l in the Lemanak river villagers (p < 0.0001). Goitrous subjects tended to have lower urinary iodine concentration than non-goitrous subjects. In the males, smoking of tobacco was associated with a two-fold increase in goiter frequency. Despite on-going distribution of iodized salt by the medical and health services in the State, only 23% of the 135 salt samples obtained from the households in the areas contained detectable iodine.
A comparative epidemiological and anthropometric survey was conducted among Ibans, the largest indigenous ethnic group in Sarawak, in three regions where the endemicity of goitre exhibited marked differences , to assess the effect of endemic goitre on somatic growth. In the Ai river region the prevalence of goitre was 99.5%; 35% having grade 3 goitres, 55% grade 2 goitres and 9.5% grade 1 goitres. At Rubu the prevalence of endemic goitre was 74%; 3% having grade 3 goitre, 16% grade 2 goitre and 55% grade 1 goitre. In the Bajong region relatively few people were detected with goitre and most of these had migrated from other regions. Neurological cretinism was estimated at 3.6% in the severely goitrous Ai river population but was not detected in the other regions. Anthropometric data obtained from the three adult populations did not reveal any statistically significant differences in the following parameters: weight, height, weight/height ratio, height/sitting height ratios, head circumference, scapular skinfold thickness and left mid arm muscle circumference. The haemoglobin, serum total protein and serum albumin concentrations were similar in the three populations. It is concluded that endemic goitre occurs with a frequency of close to 100% in certain Iban populations which represents one of the highest incidences of endemic goitre in the world. Neurological cretinism is common in this population. Our observations suggest that body proportions and somatic growth do not vary among similar ethnic populations exhibiting greatly different endemicity of goitre. Although no iodine balance studies were performed, assessment of diets suggested that iodine deficiency is a significant contributory factor in the development of endemic goitre in Sarawak. Urgent attention to iodine supplementation is indicated to prevent the development of endemic goitre and neurological cretinism.
A patient is said to have subclinical hyperthyroidism if he has a depressed thyroid stimulating hormone (TSH) level but is clinically euthyroid and has a normal thyroxine (T4) and triiodothyronine (T3) level. The aetiology of this condition is unknown, its progression is uncertain and the value of treatment is doubtful. These 2 cases show a rapid reversal of TSH suppression within a week after thyroidectomy. This suggest an unidentified potent but innocuous suppressor of TSH is produced by some large nodular goitres. Patients with multinodular goitres with subclinical hyperthyroidism can have their anxiety allayed with assurance that their condition is benign and that their TSH suppression is due to the presence of an innocuous substance which is protective in nature. This substance, when isolated, will find a useful place in the prevention and treatment of papillary carcinoma of the thyroid because of its potent effect on the pituitary-thyroid axis without causing any peripheral effects.
A massive goiter may constrict the trachea resulting in shortness of breath. Recurrent laryngeal nerve compression may cause vocal cord paralysis. We highlight a case of a 62- year-old female with a 30 year history of an anterior neck swelling gradually increasing in size. She presented with acute symptoms of upper airway obstruction and voice changes. Emergency thyroidectomy was performed by dividing the middle part of the gland using ultrasonic scissors. The recovery was uneventful and the patient regained normal vocal cord function post operatively.
Massive goiter with retrosternal extension may impose additional risk such as difficult intubation, tracheomalacia, and possibility of different incision and approach including sternotomy. We would like to report a case of massive goiter encasing major neck structures and how it was managed.
A case of non-recurrent laryngeal nerve is reported. The non-recurrent laryngeal nerve was found on the right side and was not associated with any vascular abnormalities. The anatomy and surgical implication of this rare condition is discussed
A large-scale study was undertaken in the state of Kelantan, to determine the prevalence of goitre. A total of 2,450 subjects above the age of 15 years were selected from 31 localities in the state and examination for goitre was done using the technique of Perez. The state was divided into 3 areas--coastal area (area 1), inland area (area 2) and the area in between the coast and the inland area (area 3). The overall prevalence of goitre was 36.8% and the prevalence in areas 1, 2 and 3 were 23.0%, 35.9% and 44.9% respectively and ranged from 6.9% in a locality in area 1 to 59.7% in a locality in area 3. In all areas, the prevalence was higher in females than in males. The prevalence of grades I, II and III goitres were 21.5%, 1.0% and 0.5% respectively in area 1, 33.6%, 1.5% and 0.7% respectively in area 2 and 41.7%, 2.2% and 1.0% respectively in area 3. Amongst age groups, goitre prevalence was highest in the 36 to 45 years age group in area 1 (33.9%), in the 15 to 25 years age group in area 2 (39.6%) and in the 26 to 35 years age group in area 3 (54.3%). In all the areas, goitre prevalence was lowest in the above 56 years age group. We concluded that the prevalence of goitre was high in Kelantan and there were regional differences in the prevalence rate within the state.
The study was conducted to compare the prevalence of goitre among Malays and Aborigines in remote inland rural areas to those in coastal areas. All subjects were examined thoroughly by an experienced endocrinologist for the presence of goitre. The overall goitre prevalence in coastal areas was 6.3%; 6.0% (4/67) of Aborigines and 6.7% (4/60) of Malays were affected. However, in remote inland areas, the prevalence of goitre was almost 5 times higher compared to coastal areas. The prevalence of goitre was 30.7% in Baling; 30.2% (19/63) Aborigines and 30.8% (92/299) Malays were affected. Iodine deficiency is the most likely cause for the high prevalence of goitre in the remote inland areas.
The prevalence of goitre was investigated in a sample from six longhouses and five primary schools located at varying degrees of remoteness along the Tinjar river, Sarawak. Together with this, a survey was made on the type of salt used by the households. The main ethnic groups in these communities were the Kenyah/Kayan and the Iban. The overall prevalence of palpable goitre detected from the age group 5-14 years were 71.7 percent and 77.0 percent for males and females respectively and 77.7 percent for females aged 15 years and above. The prevalence for both Iban and Kenyah/Kayan of either sex and for all age groups varied from 63.4 percent to 80.4 percent. The prevalence at each location did not differ significantly. On questioning 126 households, only 9 (7.1 percent) used iodized salt whilst 74 (58.7 percent) households used only uniodized coarse salt and 7 (5.6 percent) used only uniodized fine salt. The remaining 36 (28.6 percent) households used both fine and coarse uniodized salt. Undoubtedly at this point in time legislation on "table" salt iodization must be interpreted to mean not only the iodization of fine table salt, but in the case of the rural longhouse communities as are found in the Tinjar area, the iodization of coarse salt as well.
The clinical, biochemical and pathological features of 31 patients with thyroid carcinoma managed at Hospital Universiti Sains Málaysia, Kubang Kerian from 1985 to 1989 were analyzed. There were 25 females and 6 males. The types of carcinoma were: papillary-17 cases; follicular-10 cases; medullary-2 cases and anaplastic-2 cases. For papillary carcinoma the mean age of the patients was 52.9 years. For follicular carcinoma the mean age was 48.3 years, for medullary carcinoma, 48.5 years and for anaplastic, 74.5 years. All patients had pre-existing goitre except for 2 and most presented with advanced disease. The mean duration of symptoms for papillary carcinoma was 3.7 years, follicular carcinoma 1.6 years, medullary carcinoma 13.5 years and anaplastic carcinoma 6 months. 12 patients presented with goitre of increasing size; 9 had compression symptoms; 4 presented with cervical lymph node enlargement and 6 presented with bony pains of whom 2 had paraplegia. None of the patients were ever thyrotoxic or hypothyroid. Treatment in general was unsatisfactory because of patients' non-acceptance of surgery and/or radioactive iodine.
Eight longhouses were selected randomly for a goitre survey in the Entabai area of the Sixth Division, Sarawak. 645 subjects were examined and a goitre prevalence of 46.4% (15 years and above) was found. The females had a higher rate of 69.5% as compared with their male counterparts with 24.4%. Below the age of 15 years, prevalence was low and there was not much difference between the two sexes. After the age of 15 years, the prevalence among the females
increased from 40% to almost 80% by the age of 25 years. The males, on the other hand, showed a decrease in prevalence after the age of 15 years and levelled off at about 30%. The females also had much larger goitres than males. About 43% of the households surveyed consumed iodised salt but the rates tend to fluctuate according to supplies. There was however no direct correlation between goitre prevalence and consumption of iodised salt.
1. Observations have been quoted which mention the existence of goiter in remote inland areas of Malaya. 2. 39.5% of 618 Malays and 40.8% of 710 aborigines from inland areas were found on examination to have visible thyroid glands. A high incidence of thyroid enlargement was found in almost all areas where these observations were made, on a wide range of Geological Formations. 3. In the seaside populations studied, the low incidence of ‘visible’ thyroid glands (2/184) is typical of that of other ‘goiter free’ areas. 4. Iodine estimations have been carried out on seven water samples from rivers draining inland areas where thyroid data have been collected, and gave values of 0.2 to 0.6 parts of iodine per thousand million. The development of goiter is to be expected when the iodine content is so low. 5. High calcium content of waters cannot be important in causing goiter in Malaya. 6. The availability of dried seafoods is thought to be an important factor in goiter prevention in Malaya. Four dried marine foods contained 360 to 1,340 parts of iodine per thousand million.
1853 thyroid lesions subjected to cytological sampling (either by the fine needle aspiration or fine needle capillary sampling technique) from January 1992 to December 1997 at the University Hospital, Kuala Lumpur, were reviewed. Nodular goitre was the most common thyroid lesion needled (67.35%). Among the neoplastic lesions, follicular neoplasms predominated (64%), followed by papillary carcinoma (29.4%). In 325 cases, partial or total thyroidectomy had been done, providing material for histological review and cyto-histological correlation. Cytological diagnosis was found to have high sensitivity and specificity rates of over 75%. Besides, most non-neoplastic thyroid lesions could be diagnosed on cytology. The scope of cytology in the diagnosis of lymphomas, anaplastic and metastatic tumours rendered diagnostic biopsies (or thyroidectomy) unnecessary in these cases. Being a cost-effective technique and having the capacity to provide exact morphological diagnosis in a large variety of thyroid lesions, cytology is obviously the method of choice in the assessment of thyroid nodules.
From 1996 to 2001, 393 thyroidectomies were performed and 25 (6.4%) patients underwent reoperative thyroid surgery at Hospital Universiti Sains Malaysia. All reoperated patients had undergone one prior thyroid operation. All were females with an average age of 39.1 years (18-61 years). The most frequent indication for reoperation was cancer in resected specimen of an originally misdiagnosed carcinoma treated by partial thyroid resection. Final histological diagnosis of 25 reoperations showed thyroid carcinoma in 22 (88%) cases and multinodular goiter in 3 cases. The overall interval between the initial and the reoperative procedures ranged from 3 weeks to 15 years. There was no post-operative mortality after reoperation. Post-operative complications were discovered in 5 patients, as 3 (12%) of whom had transient hypocalcaemia, one (4%) had wound breakdown and one (4%) had permanent recurrent laryngeal nerve palsy. Reoperative thyroid surgery is an uncommon operation with high complication rate.
Goitre is a slow-growing thyroid mass, rarely presenting as an emergency. However, a superimposed infection or acute intralesional bleeding can cause the mass to increase rapidly in size. We report a patient with long-standing multinodular goitre who presented with bleeding from the left thyroid mass. Despite all appropriate measures, the continuous bleeding finally stopped upon thyroidectomy.