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.
Antithyroid drugs, radioiodine and surgery are lhe three modalities of treatment for Graves' hyperthyroidism. The treatment strategy depends on a clear understanding of the relative advantages and disadvantages of each mode of treatment as well as the individual patient's preference. Recent studies favour the use of high dose antithyroid drugs with thyroxine supplementation to induce a higher rate of remission. Radioiodine is likely to be favoured as the definitive form of treatment. Surgery still has a place particularly for young female patients with large goitres. Keywords: Antithyroid drugs, radioiodine, thyroidectomy.
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.
Left ventricular non-compaction cardiomyopathy (LVNC) is a rare congenital cardiomyopathy, which is
characterized by hypertrabeculations and deep recesses of the left ventricle. A patient could be
asymptomatic or presented with common manifestations, including reduced systolic function, arrhythmia,
thromboembolic events and heart failure. The rarity of the condition as well as lack of proper assessment
has probably led to this condition to be largely underdiagnosed or unrecognized. A 23-year-old lady had
collapsed at home thirty one days after delivering her first child. She had a history of goitre diagnosed a
year ago and noted to be fairly well throughout the pregnancy. Post mortem findings showed increased
trabeculations of the left ventricle. Further history was obtained after the procedure, revealing symptoms
such as syncopal attacks and bilateral lower limb weakness dated back as far as five years prior to her
sudden demise. These features were in keeping with hypotension hypoperfusion effects resulted from
reduced systolic function and decreased ejection fraction, as a result of left ventricular dysfunction. While
LVNC remains a rare type of disease, we would like to highlight the importance of a good anamnesis. It may
help to uncover some uncommon pathology such as this heart disease, thus warranting an appropriate
cardiac imaging to be engaged to clinch the primary diagnosis.
Background: Thyroid swelling or goitre is a common condition, either asymptomatic or symptomatic. The
diagnosis is usually established by ultrasound or fine needle aspiration cytology (FNAC) as a gold standard.
The sensitivity of the test is inversely related to increasing size of the nodule. The objective of this study is
to evaluate the accuracy of FNAC especially in cases of large goitre.
Material and methods: This is a
retrospective study on patients who underwent thyroidectomy between January 2000 to December 2007 for
solitary or dominant nodular goitre. The analysis was made only on those patients with complete data on
FNAC and histology.
Result: There were 235 patients, but only 161 patients were analysed after excluding
the suspicious and inadequate sample. The patients’ mean age was 42.1 year old (21 to 60). The size of the
thyroid nodule ranged from 2.1 to 5.0 cm (mean = 3.9 cm). The overall sensitivity was 67.4% and the overall
accuracy was 86.3%. The accuracy of FNAC according to the sizes above and below the value were as
follows; 2 cm (72.2% vs. 88.1%); 3 cm (88.0% vs. 87.4%) ; 4 cm (86.6% vs. 84.4%) ; 5 cm (87.3% vs. 78.8%).
This was most obvious in the sensitivity of the FNA which also showed reducing trend as the nodules
increased in size.
Conclusion: FNAC is an essential diagnostic tool in the management of nodular goitre.
Our study showed that the accuracy of FNAC decreased as the size of the nodule getting bigger. Cautious
approach should be taken in the management of large goitre and decision should not be based only on the
result of FNAC.
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.
OBJECTIVE: To review our experience of total thyroidectomy for bilateral multinodular goitre.
DESIGN: Prospective open study.
SETTING: Teaching hospital, Malaysia.
SUBJECTS: 98 consecutive patients whose bilateral multinodular goitres were treated by total thyroidectomy, January 1998-November 1999.
INTERVENTION: A revised technique of total thyroidectomy in which more attention than is customary was paid to the exposure and safety of the laryngeal nerves and the parathyroid glands. All patients had at least 1 parathyroid gland autotransplanted.
MAIN OUTCOME MEASURES: Morbidity and mortality
RESULTS: There were no injuries to the recurrent laryngeal nerves and no patient developed persistent hypocalcaemia; 27/98 developed transient hypocalcaemia, but this had settled by 6 months postoperatively. 59 patients had persistent symptoms of pressure preoperatively, and these all resolved by 3 months postoperatively. 6 patients had occult malignant disease discovered on histological examination, and 3 developed minor wound infections.
CONCLUSIONS: Total thyroidectomy is the procedure of choice for bilateral multinodular goitres, provided that sufficient attention is paid to the preservation of the laryngeal nerves and the parathyroid glands.
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.
The decision for median sternotomy for retrosternal goiter is complex and proper consensus are lacking. Generally, it is based on clinical, radiological and intraoperative assessment. Among the few known features include primary mediastinal goiter, posterior mediastinal goiter and recurrent retrosternal goiter. We present a patient with posterior mediastinal, secondary goiter that extended until the tracheal bifurcation. The goiter was removed successfully via a low cervical incision and this was achieved by dissecting along the anatomical plane close to the thyroid capsule using blunt dissection with fingers. It is possible for these kinds of high risk retrosternal goitres to be safely removed without the need for thoracotomy when the surgery was performed along the proper plane.
Iodine deficiency is recognized as a public health problem. This paper assesses iodine status by socioeconomic factors in school children in Sarawak, East Malaysia. Kuching, Bau and Simunjan districts were chosen based on advice from the Sarawak's Medical and Health Authority. 803 school children, aged eight years, were selected from 19 schools via proportionate systematic sampling. About half the proportion of the school children were from Kuching, 24% from Simunjan and 22% from Bau. Almost all were equally distributed by sex. By mother's race, almost half were Malays, followed by Bidayuh, Iban, Chinese and other races. Mean urinary iodine concentration was 3.36 microg/ 100ml, mean creatinine level was 111.10 mg/100ml and mean creatinine/iodine ratio was 39.45 microg/ gram. Four female children (0.5%) were found to have enlarged thyroid. Urinary iodine levels were significantly different by district, mother's race and household income. It was highest in Kuching, among children with Malay mothers, and with household incomes more than RM500 per month. Conversely, it was lowest in Bau, among children of Iban/Dayak and Chinese mothers, and incomes of RM500 or less per month. Based on the WHO/UNICEF/ICCIDD classification, the Sarawak school children in the present study fall into the moderate IDD category. The low prevalence of goitre is a positive finding indicating that iodine deficiency is corrected over time.
Thyroid enlargement is one of the common surgical presentations in the Department of Surgery, Hospital Universiti Sains Malaysia (HUSM). Among them, benign non-toxic multinodular goiter constitutes one third (30%) of patients who underwent thyroidectomy. Common complications of thyroidectomy include recurrent laryngeal nerve (RLN) injury, hypocalcaemia, and recurrence of the thyroid lesion. Objective & Methods: This is a retrospective study of patients diagnosed with multinodular goiter treated in HUSM between January 1996 and December 2005. A total of 111 patients were studied and 52 of them underwent subtotal thyroidectomy while 59 underwent total thyroidectomy. The outcome in terms of RLN injury, hypocalcaemia and mass recurrence were analyzed. Results: Post operative complications were studied in both groups. Permanent recurrent laryngeal nerve injury occurs in 2.4% (1 case) in subtotal thyroidectomy group compared to total thyroidectomy group (3.6%, 2 cases). Five cases from total thyroidectomy group suffered from permanent hypocalcaemia but none in the other group. 70.7% (29 cases) from subtotal thyroidectomy group have functional remnant of thyroid tissue. Recurrence rate post subtotal thyroidectomy after 5 years is only 4.9% (2 cases). Conclusion: The post operative outcome in patients who underwent subtotal thyroidectomy in HUSM from January 1996 to
December 2005 was better than total thyroidectomy with significant functional thyroid remnant.
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.
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.
To investigate RET and p53 expression in local thyroid lesions, in order to shed light on the pathogenesis of papillary carcinoma and explain the high prevalence of this condition among the nodular hyperplasia (multi-nodular goitre) cases.
Four areas of differing remoteness were studied to determine the prevalence of goitre in the Keningau Division of Sabah. These areas were Keningau town, the Biah Resettlement Scheme, the Dalit subdistrict and the Pagalunggan subdistrict. The predominant ethnic group in these areas is the Murut. The overall endemicity of goitre for the study population was 76.5% for females aged 15 years and above. There was a significant correlation between the incidence of goitre and the remoteness of an area. The Dalit subdistrict has the highest incidence of goitre (82.6%) followed by the Pagalunggan subdistrict (77.8%), the majority of these goitre cases being classified as grade 2 (visible goitres). These were the two most remote areas in the study. In contrast, Keningau town, the least remote area has the lowest incidence of goitre (62.5%) with most of the goitres being relatively small. With regards to salt usage in the Dalit subdistrict, only 3.0% used iodised salt; 28.0% used fine salt; 3.6% used coarse salt and 65.5% used both fine and coarse salt. In the Pagalunggan subdistrict, all females used uniodised salt with 17.6% using fine salt, 20% using coarse salt and the remainder using both fine and coarse salt. As yet, there is no legislation for the iodisation of salt in Sabah. It is clear that all types of salt need to be iodised and adequately distributed to deprived areas, particularly inland areas.