By Tedler D. Depaynos, MD
The patient came from a remote barangay of a distant Benguet municipality near Mt. Pulag accompanied by a granddaughter who apparently made good abroad not only in sending home dollars but also in bringing home a dark handsome all smiling tall foreigner that emphasized the shortness of the patient. Except for a huge nodular mass protruding from her anterior neck with apparent heaviness, she was asymptomatic. Obviously she has an enlarged thyroid gland called goiter and because she has no manifestation of toxicity or is euthyroid it is called Simple or Non-Toxic Goiter in medical parlance. The word “simple” may appear however a misnomer in street language considering the hugeness of the mass.
The patient mentioned that many of her relatives as well as “barangay” mates have similar “goiter” and some of them have already entered the “other world”. They live in the mountains and their main livelihood is planting vegetables. Younger males are venturing into private mining and because of occasional “luck” they may indulge in other foods but their staple nourishment is basically the same. Their condition obviously is called Endemic Goiter and the main pathology is lack of iodine which comes mainly from sea foods. The consulted surgeon over a cup of black coffee with unending refills mentioned that he could remember his old professor lecturing that one cause of Endemic Goiter is the intake of cabbage. The professor, however, failed to emphasize that to have Goiter a truckload of the vegetable should be eaten. Of course the truckload could be eaten in years.
Iodine is used by the body in the synthesis of the thyroid hormones and when these are lacking the thyroid gland enlarges so it could produce the normal level that the body needs. The enlargement then is a compensatory mechanism to prevent hypothyroidism or lack of thyroid hormones.
In Endemic Goiter, the enlarged thyroid gland may be diffused and smooth. In many cases it may become nodular of different sizes and number especially with time just like in this patient. “Gelatinous colloid-rich material” may fill up the nodules and the areas in between them are made up of normal thyroid tissues. In some cases the nodules may suddenly enlarge in size and may be painful and this may be due to bleeding.
The patient never sought consultations because she was not feeling anything which is usual in elderly patients especially those in the rural areas where MDs are distantly located. Despite the enlargement she never complained of difficulty of breathing or swallowing which may appear in some patients because of compression. Others may complain of gradual hoarseness or change of voice which may be due to nerve compression. In these cases, experienced surgeons entertain the possibility of malignancy. Some elderly patients, however, attribute this to the long non-stop “chanting” they do during some native rites.
Some long standing Nodular Goiters are observed to develop “cancer” or may cause “hyperthyroidism”.
Simple Endemic goiters maybe insidious and instead of bulging outwards, they may extend into the thoracic cavity and may become retrosternal. It may impede the blood returning to the heart thru the jugular veins and may cause “flushing” which may be aggravated by the raising of both arms. A prominent lawyer who was observed later to be always “flushing” in court by a judge was diagnosed to have this rare condition and underwent a “retrosternal thyroidectomy”.
As expected the patient’s laboratory tests especially the thyroid function tests were within normal limits except for a slight anemia. She refused however to undergo a Fine Needle Aspiration Cytology (FNAC) which is now routinely done by Endocrinologists and some young surgeons mainly to eliminate the possibility of malignancy. It could also drain the colloid filled nodules if they are small and could be done repeatedly which may be the needed therapy instead of surgery.
Because the cause of Simple Goiter is lack of Iodine, Iodine is routinely prescribed. The patient mentioned that they take “tilapia” from Ambuklao Dam occasionally when her children sell their products to the city but not to discourage her, the consulted surgeon just mentioned that it is not enough instead of arguing that it is a fresh water fish and lacking in Iodine.
To reduce the size of the goiter, Thyroxine which is actually a thyroid hormone is sometimes prescribed but this is strictly monitored because the patient may manifest “toxicity”. Hence, because the regular monthly follow-up of the patient was doubtful despite the pleadings of her granddaughter, it was not prescribed.
From the old surgical textbooks of the consulted surgeon, surgery for Simple Goiter is reserved for huge cosmetically unacceptable goiters, those with compressive manifestations, those located retrosternally and of course those with possibility of malignancy after FNAC.
Despite the pleadings of her granddaughter and tall grand son-in-law the patient refused surgery because anyway she lives in the mountains and was already more than senior already. She just requested that the supposed to be expected hospital expenses be left with her so she could buy “sea foods” as advised by her surgeon including the prescribed medicines.**
