A 46-year-old Malay woman presented with a neck swelling that had gradually increased in size over 12 years. Examinations and investigations confirmed advanced papillary thyroid carcinoma with metastases. She underwent a total thyroidectomy with complications of hoarseness of voice and hypocalcemia managed conservatively. Further radioactive iodine therapy was planned after thyroxine treatment.
4. She noticed the swelling 12 years ago while looking at
herself in the mirror during her last pregnancy
At that time the swelling was as big as a 20 cents coin
located at the anterior of her neck on the right side,
after delivery the swelling persisted and over 12 years
it gradually increased in size, currently as big as a
5. It was :
not painful
there was no skin changes on the overlying skin
no other swellings
Does not complain of obstructive symptoms such as:
shortness of breath
difficulty in swallowing
However she had unintentional weight loss where she had lost 12
kilograms in the past 2 months
6. Her menstruation has been irregular for the last 2
years missing up till 3 months at times. And her
menstruation bleeding lasts only for 2 days where she
uses 2 pads per day, not fully soaked
Otherwise, she denied any hypo or hyperthyroid
symptoms such as heat/cold intolerance, tremors,
palpitation, anxiety, sleeping difficulties, irritability,
frequent perspiration, muscle weakness, depression,
lethargy, constipation or diarrhea.
7. No history of exposure to radiation previously or history
of living in highlands
She does not have cough, bone aches/ history of
fractures
She initially presented to Hospital Tawau early this year
where an FNAC was done with results suggesting
Papillary thyroid carcinoma, she was than referred to
Putrajaya hosp for total thyroidectomy and further
management
8. She has no known medical illness
Never been hospitalized for other reasons besides
child birth
9. She is not on any medication
Does not use over the counter drugs or traditional
medicines
There are no known drug allergies
She is not allergic to any food
10. She is a divorcee living with 3 out of her 5 children
ranging from 25 years old – 12 years old
She used to work as a laborer in a provisional store
but has stopped working for the last 3 years as 2 of
her children had started working
The 2 eldest children support her financially
Currently she stays at home and does chores around
the house
She lives in a rented wooden house in tawau
She does not smoke and does not consume alcohol.
11. None of her family members suffers from a similar
condition.
Her mother is well
her father passed away because of old age
No family history of thyroid disorders or malignancies
14. General examination
My patient is sitting in bed. She is of average built,
She is conscious and orientated to time and place.
She has no clubbing, no pallor, no jaundice no
koilonychia, no onicholysis, her palms are moist and
sweaty, there is no fine tremor, her skin is not dry
15. Vital signs :
No signs of pretibial edema
Eyes
no peripheral loss of eyebrows, conjungtiva not
injected, not pale, no exopthalmus,no lid retraction or
lid lag
Temperature 37 ⁰C
Pulse 88 bpm
Blood pressure 140/90 mmhg
Respiratory 15 breaths per minute
16. Neck examination
Inspection:
diffuse swelling at the anterior neck extending from
the posterior margin of the right
sternocleidomastoideus muscle to the anterior border
of the left sternoccleidomastoideus muscle , vertically
and from the hyoid bone down to the sternal notch
It moves with deglutination and does not move with
the protrusion of the tongue
The jugular vein is not distended and no dilated veins
over the swelling
no surgical scars
no other skin changes
No other swelling seen
17. Palpation
Warm, non tender, position of the trachea cannot be
appreciated
irregular shape swelling measuring 22 x 15 cm with
smooth surface and firm consistency, well defined
edge on the left side but not on the right side
(irregular), moves with swallowing, mobile vertically
and laterally, not attached to the overlying skin and
or underlying structures, no fluctuance, not pulsatile,
no thrill
the carotid pulse absent on left sign
no cervical or supraclavicle lymph nodes palpable
18. Percussion
There is no retrosternal extension of the lump
Auscultation
There is no bruit heard
Hoarseness of voice present
19. Condition Supporting
Thyroid Malignancy Increase in size, LOW, age, sex,
hoarseness of voice, possible
history of long standing goitre
Goitre Age, sex, diet, noticed during
pregnancy
20. Inv results
Full blood count Hb: 11.5
Hematocrite 34.3
Platlet : 225
TWC: 6.1
TFT T4 3.23 pmol/L (9-24) (L)
TSH 29.20 (o.49-4.67) (H)
Random blood sugar 5.06 (n)
Liver function test NORMAL
Renal profile Urea 3.7 ; Na:139 ; k:1.9 ; creatinin:37
Coagulation profile INR: 1.145
Ptt :27 (23-40) n
Pt : 12.7 (11-16)n
21. Inv results
Serum Calsium’ 2.23
Serum phosphate 1.31 (0.8-1.6) N
Neck Ct scan highly suggestive of cancer of thyroid
with invasion to larynx including vocal
cords and hypopharynx
Metastasis to cervical lymph nodes
and bilateral lungs
Histopathology
(biopsy)
Trucut biopsy suggestive of papillary
thyroid cancer
22. ECG
Chest x-ray
Vocal cord assestment Right vocal cord – with 70 degrees
scope
-Rt vocal cord immobile on resp and
phonation
-Lf vocal cord mobile , gap present on
phonation
TRO rt vocal cord palsy
24. 1. Monitor TFT
2. Blood pressure monitoring
3. To start patient on L.Thyroxine 100mcg OD
4. Start patient on amlodipine 50mg
5. Lung function test
6. Echocardiography
7. Incentive spirometry for patient
8. Total thyroidectomy planned for 28th
July 2011
9. To repeat all blood investigations pre-op
25. Lung function test Normal ventilatory function
Echocardiography Ejection fraction 73%, with no LVH and
mild MR
18/7/2011 27/7/2011 :
TFT showed fluctuating results ranging from T4 and TSH from
L-thyroxin was started initially as patient was subclinically hypothyroid
however withhold at certain periods where TFT showed normal or
hyperthyroid.
Repeated blood examinations no significant difference
26. 27th
July 2011
T3: 7.06 ( raised) TSH: 3.23 (N)
Plan
1. Continue with the surgery
2. NBM 6 hours prior to surgery
3. Give anti-hypertensives + sips of clear fluid on day of
operation
4. GXM 6 pints of blood, 2 point in OT and 4 standby in
lab
27. Rt lobe of thyroid replaced by tumour measuring 10 x
10
Adherent to strap muscle
Rt IJV thrombosed with tumour
weight of gland 668 gram
Right carotid artery free from tumour, vagus nerve
preserved
Right recurrent laryngeal nerve not seen
Right parathyroid glands not seen
Tumour infiltrated trachea and shaved off
28. Left thyroid lobe normal
Left superior parathyroid gland seen however inferior could not be seen
Strap muscle which has infiltrated by tumour was excised
2 drains was placed, left and right
Intra-op diagnosis : Advanced Follicular Thyroid Carcinoma
Intra –op v/s: 110-90/60-57 mmhg, 60-70 bpm, SpO2 97-98
Intra-op ABG: 7.33/44/122/-2.1/22.9/99.4%/lac 0.9
CVP: 11-15
Hb: 10.9 g/dl
Plan
Pt sent to ICU intubated, on ventilator and sedated cont IV midazolam,
IV morphine 2mg/hourly
29. IV ranitidine 50 mg tds
IVD 2NS 2 DSIV
IV ca gluconat 1 g tds 1/7
Repeat blood examinations in ICU (FBC,
coagulation screeen, RP, ABG, serum calsium post
op 6 hours than bd)
ECG stat in ICU
i/o charting
DVT foot pump
Extubation cm
30. Completed 4 pints of packed cells
Completed 2 unit of FFP
Phy examination:
Vital signs
Lungs clear, CVS DRNM
Bp 120/64 mmhg
Pulse rate 55 bpm
temperature afebrile
31. Drain
Significant inv results:
Hb: 11.2 (N)
platlet 151 (N)
Rp creat 42
ca: 1.912.01 (L)
inr/pt/aptt : 1.1/26/13.1 (N)
Drain amount
Right (functioning) 50 cc hemoserous
Left (functioning) 50 cc hemoserous
32. Plan
2 units of FFP
Once tolerating orally start Ca. lactate 2 tabs tds
Cont VM post extubation
FBC and Coagulation screen daily
Endocrine: plan to get RAI therapy date prior to start of
thyroxine therapy
33. ICU day 2
Hb 11.5 g/dl, pt/aptt: 27/12.7 N
Off cbd, ryles tube, of ivi morphine
Start tab tramadol 50mg td + ca lactate 2tab tds
Chest physio
Trace TFT/alb(33)
ICU day 2 (evening)
Extubated, change to CPAP ,pt comfortable
Hoarseness of voice>>>promient
Changed to VM 50% cmabg 7.45/33/178/231/-0.2/99%, lac 0.6
Ca: 2.06 (L) add ca lactate 4 tab qid + alfacalcidol 1 mcg od
repeat ca cm (2.08)
Start l.thyroxine 200 mcg odRAI date only in September
Cont other medications
Allowed to ward +incentive spirometry and chest physio
34. POD3-POD5
Pt v/s normal,ambulating
Hoarseness of voice not worsening
Bp: 146/81 pr: 88
No hypocalcemia symptoms
Lungs clear, cvs DRNM
Wound clean, no hematoma drains
Chovstek sign (-)
POD 3 Ca 2.08- on calsium gluconate IV tds and ca. lactate
4 tab qid +alfacalcidol
IV ca stopped and serum ca on POD4 : 2.10
drains amount
right 50 cc
left 30 cc
35. Pod 6
-patient allowed for discharge,
-remove drain
-referral to Tawau hosp for follow up and medication
-tab L-thyroxine 200mcg od 2/12
-tab calsium lactate 300mg x 3 od 2/12
-cap alfacalcidol 1 mcg od
-amlodipine 5mg od 1/12
-PCM 500mg x 2 qid 1/12
42. AACE Clinical Practice Guidelines for the Diagnosis and
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84.
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the management of well-differentiated papillary thyroid
carcinoma. J Clin Endocrinol Metab 1996;81:333-339.
Pyke CM, Hay ID, Goellner Jr, et al. Prognostic
significance of calcitonin immunoreactivity, amyloid
staining and flow cytometric DNA measurements in
medullary thyroid carcinoma. Surgery 1991;110:964-970.
Bailey and love Surgery textbook
