CASE PRESENTATION
STRUMA NODUSA
By :
Wina Hanriyani 1102012307
Preceptor :
Dr. HERRY SETYA YUDHA UTAMA, SpB, MHKes,FInaCS
Clinical Clerkship of Surgery Department
Faculty of Medicine YARSI University
RSUD Arjawinangun
December 2016
Case Presentation
I.
Identity
Name
Age
Gender
Tribe
Occupation
Address
In hospital since
: Ms. S
: 58 years old
: Female
: Javenese
: Gardener
: Kuningan
: December 8th 2016
II.
Anamnesis
Main Grievance
Additional Grievance
III.
: Lump in the neck
: Do not feel tightness and bumps elsewhere
Historical of Present Disease
A 58-year-old woman, came to the clinic and surgical Arjawinangun hospital with the
chief complaint there is a lump in the neck that are known about 5 years ago. Previous
lumps are small and do not complain of pain, the longer the lump growing.
Pain in the palpable lumps and bumps palpable hard, joined swallowing movements.
Complaints accompanied by heart palpitations and a hoarse voice.
IV.
V.
Historical of Past Disease
Patients had never performed the operation.
Diabetes mellitus (-),
Hypertension(-)
History of the head and neck radiation (-)
History drugs - thyroid drugs and drugs other long-term (-)
Historical of Family Disease
No family in the neighborhood of patients who have a complaint similar to the patient
VI.
Physical Examination
General Status
Present Status
General Condition
Awareness
Blood Pressure
Pulse
Breathing
Temperature
: Moderate
: Composmentis
: 140/90 mmHg
: 96 x/minute
: 24 x/minute
: 36,4 C
Head
Form
Hair
Eye
: Normal, Simetrical
: Black Colour, No hair fall
: Anemic Conjungtival -/-, Icteric Schlera -/-, Light Refleks (+), Isocorpupil
Ear
Nose
Mouth
right = left
: Normal form, cerumen (-), tympani membrane intac
: Normal form, No septum deviation, epitaction -/: Normal
Neck
Enlargement lymph nodes (-)
Trachea in the middle
palpable masses
Thoraks
Lungs - pulmonary
Inspection
: The chest shape is symmetrical both of left and right
Palpation
: Fremitus tactile and vocal symmetrical right and left, crepitus (-), tenderness
Percussion
Auscultation
(-), rebound tenderness (-)
: Sound of resonant in both lung fields
: Sound of vesicular and bronchial the entire lung field, ronkhi -/-, wheezing
-/-
Abdomen
Inspection
Palpation
Percussion
Auscultation
Extremity
Upper
: Normal
: Tenderness (-), rebound tenderness (-)
: Tympani
: Bowel (+)
: Muscle Tone
Movement
Mass
Strenght
normal
: active / active
:-/: 5/5
2
Lower
Genitalia
Edema
: Muscle Tone
Movement
Mass
Strenght
Edema
Swelling
: normal
:-/:normal
: active / active
:-/: 5/5
:-/:-/-
Status localist
At the regio colli
Inspection: visible mass in the neck front, the same color with the color
the skin around, rubor (-)
Palpation: mass palpable size 5,6 cm in teh neck. consistency a hard, flat surface, fixed to (+),
pain press (-), blood (-), Pus (-), tracheal deviation is difficult to assess.
Auscultation: bruit (-)
Laboratory Examination
Normal
Diagnosis
Struma Nudosa
Management
-
Inf RL 20 tts / min
Cefoperazon 2x1
tramadol 2x1
Ranitidine 2x1 amp
Surgical therapy
Operative plan thyroidectomy
Prognosis
Quo ad vitam
Quo ad fungsionam
Quo ad sanationam
VII.
: Dubia ad bonam
: Dubia ad bonam
: Dubia ad bonam
Literature Review
Goitre, nontoxic NODUSA
3
Struma nodosa is nontoxic struma nodosa without accompanying signs of hyperthyroidism.
Enlargement of the thyroid gland is not an inflammatory or neoplastic process and not
associated with thyroid function abnormalities.
Etiology
Struma nodosa nontoxic arise from the interaction of environmental, genetic and endogenous
factors. Some etiology is:
1.
Iodine deficiency iodine intake of less than 50 mcg / day. Iodine deficiency is the
most common cause of endemic and sporadic nontoxic goiter.
2.
excess iodine rare and usually occurs in patients with a previous history of
autoimmune thyroid disease.
3.
goitrogens:
- Medication: propilthiouracil (PTU), phenylbutazone, lithium, p-aminosalicylic acid,
aminoglutethimide, sulfonamides,
- Agent environment phenolic derivatives and Phtalate, resorcinol coal.
- Food vegetables (cabbage, cassava), seaweed.
4.Dishormogenesis
defect-derived thyroid hormone biosynthesis
5.history of head and neck radiation in childhood - childhood
6.Other risks factor: infection, emotional stress, smoking
Pathophysiology
The underlying growth of nodules on nodosa nontoxic goiter is the response of the thyroid
follicular cells are heterogeneous in the thyroid gland pad individuals. In a normal thyroid
gland, the sensitivity of the cells in the same follicle to the growth stimulus TSH and other
factors (IGF and EGF) varies widely. There is autonomous cells that can replicate without
TSH stimulation and the cells are very sensitive TSH faster replication. Cells will replicate to
produce cells with the same properties.
Follicular cell-cell functional activity varied greatly. The imbalance between the synthesis
and activity endositotik thyroglobulin this causes the growth of nodules varied.
Diagnosis
What needs to be considered in evaluating patients with non-toxic goitre is a goitre growth
patterns, symptoms of obstruction or compression and cosmetic complaints. There should
also be examined to assess the risk of malignancy.
anamnesis
-
Bumps on the anterior neck that grow slowly, not pain
A family history of thyroid disease
Enlargement of the thyroid during pregnancy
Complaints cosmetics
The existence of signs of compression and obstruction: hoarseness, stridor, shortness
of breath, difficult / painful swallowing, cough, symptoms of upper airway
obstruction.
Symptoms of hyperthyroidism may appear gradually
Symptoms of complications: bleeding pain caused by secondary, superior vena cava
syndrome and Horner's syndrome
History iodine diet
Physical examination
-
Evaluation of the thyroid gland: includes inspection, palpation and auscultation
Evaluation of signs of upper airway obstruction: dyspnoea, tracheal deviation, venous
obstruction
mark-mark thyroid dysfunction:
Hyperthyroidism: not resistant to high temperatures, increased appetite, weight loss,
palpitations, tachycardia, insomnia, tremor, exophthalmos, and squint.
Hypothyroidism: miksedem, constipation.
Usually not found lymphadenopathy
Malignancy rate
About 5% of struma nodosa undergo malignant degeneration. A careful history and
physical examination raise suspicion toward malignancy of thyroid:
Age <20 years or> 70 years
Gender male
Nodules with disfagi, hoarseness or airway obstruction
Pertumbuh nodules fast (a few weeks - months)
History radiation neck region when the child's age - child or adult (also increase the
incidence of benign thyroid nodules)
A family history of medullary thyroid cancer
Nodules are single, demarcated, hard, irregular and hard driven
Paralysis of the vocal cords
Findings cervical limpadenofati
Distant metastases (lung), ETC.
If clinically found signs of malignancy, thyroidectomy should be done even if
cytology showed a benign lesion.
Supporting investigation
1.
2.
3.
4.
5.
Tes thyroid function
thyroid
Skintigrafi thyroid
FNAB (Fine Needle Aspiration Biopsy)
Other investigations:
CT Scan or MRI solitary nodule or multiple nonhomogeneous
Pulmonary function tests disruption inspiration capacity
Here is the algorithm for the evaluation and management of thyroid nodules:
Figure 3. Algorithm evaluation and management of thyroid nodules.
Therapy
Struma nodosa nontoxic usually grows slowly and largely asymptomatic, so sometimes it
does not require therapy. Indications do therapy in nontoxic goiter is compressing the trachea
and esophagus, symptoms of venous obstruction, goitre progressive growth including
6
expansion into the chest cavity. Therapy is also indicated if there is a complaint of discomfort
in the neck and cosmetic complaints.
Therapy type
Surgery
profit
Significant reduction of goitre
Loss
risks of surgery
Decompression trachea quickly
Paralysis of the vocal cords (1%)
Eliminate the symptoms immediately -
Hypoparathyroidism (1%)
A definitive diagnosis
The risk of hypothyroidism due to
resection
-
Recurrence (depending on the type of
resection)
131
L-T4
Fewer subjective side effects
High cost
Limitations for the use of radioactive
Size reduction of 50% in one year
In
Improve the capacity of long-term
fertile
women
in
need
of
contraception
inspiration
Reduction of goitre growth slow
Can be repeated with good results
Risk of acute goitre enlargement
low Cost
(low)
-
Thyroiditis (3%)
Grave's disease (5%)
Hypothyroidism in the first year (15-
- Low cost
20%)
- Effectiveness Low
- To prevent the formation of nodules
- Treatment of a lifetime
new
- Reduction of 15- 40% in 3 months
- Adverse effects on bone and heart
- It can not be done if the low TSH
Surgical therapy
Goitre surgery can be divided into diagnostic surgery (biopsy) and therapeutic. Surgery in the
form of diagnostic incisional or excisional biopsy had been abandoned, especially after the
more accurate use of fine needle biopsy. Diagnostic biopsy is only done on the state of the
tumor can not be removed, such as in anaplastic carcinoma
A.
Follow-Surgical Indications Goitre, nontoxic:
Thyroidectomy is the treatment of choice in patients with young and healthy, especially in
cases requiring immediate decompression.
-
Cold nodules and solid.
Single nodule excision (which may be malignant)
Struma heavy multinoduler
7
Struma which causes compression of the larynx or other neck structures
Retrosternal goitre which causes compression of the trachea or other structures
Cosmetics (subtotal thyroidectomy)
B. complication Struma Surgery
1. During surgery:
- bleeding
- Recurrent nerve injury uni- or bilateral
- Injury to the trachea, esophagus, or nerves in the neck
- Tracheal collapse because Malasia trachea
- Lifting the entire parathyroid gland
- cutting duct in the neck torasiku right
2. Immediate postoperative:
- Bleeding in the neck
- Bleeding in the mediastinum
- Edema of the larynx
- Tracheal collapse
Thyroid crisis or thyrotoxicosis
3. A few hours-days pascabedahan:
- hematoma
- Wound infection
- Edema of the larynx
- Recurrent nerve paralysis
- Superior laryngeal nerve injury became apparent
- hypocalcemia
4. Old postoperative:
- hypothyroid
- Hipoparatiroid / hypocalcemia
- Recurrent nerve paralysis
- Superior laryngeal nerve injury
- Skin necrosis
- Thoracic duct leakage
Therapy post-surgery and prognosis
8
Nontoxic goitre recurrence seen in 15-40% of patients on long-term follow-up. Recurrence is
associated with postoperative residual tissue. Other factors are less influential are age,
duration of postoperative goitre and TSH levels. But with adequate surgery, recurrence rate of
no more than 10% within 10 years. Post-operative mortality rate is very low at less than 1%.
Bibliography
1. Hermus AR, Huysmans DA. Clinical manifestations and treatment of nontoxic diffuse
and nodular goiter. In: Braverman LE, Utiger RD, editors. The Thyroid. Philadelphia:
lippincot Williams & Wilkins, 2000. p. 866-70.
2. Lee S. Goiter, nontoxic. Available at: http //: www.emedicine.com.
3. Sjamsuhidajat R, Jong DW. Endocrine system. Textbook of Surgery, revised edition.
EGC 1997; 934-40
4. Hegedu LL, Bonnema SJ, Bennedbaek FN. Management of simple nodular goiter:
current status and future prespectives. USA: Endocrine reviews 24 (1): 102-132,
2003. Available at: http //: www.edrv-endojournals.org/pdf
5. MH Wheeler. The technique of thyroidectomy. JR Soc Med 1998; 91 (Suppl. 33) 1216. Available at: http //:www.pubmedcentral.nih.gov,
6. American Thyroid Association. Thyroid disease and pregnancy. Available at: http //:
www. thyroid.org.
