By Tedler D. Depaynos, MD
The patient who consulted a general surgeon 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 could recall that not only some of her relatives who already passed away have similar “goiter” but also some of their “barangaymates”. They live in the mountains and their main livelihood is planting. 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. Her condition obviously is called Endemic Goiter and the main pathology is lack of iodine which comes mainly from sea foods. The surgeon over a cup of black coffee with unending refills 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.
Iodine is used by the body in the synthesis of the thyroid hormones and since they are lacking the thyroid gland enlarges so it could produce the normal level that the body needs. Actually it 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 maybe nodular in 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 the normal thyroid tissues. In some cases the nodules may suddenly enlarge in size and may be painful and this is usually 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 M.D.s 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 they may attribute to the long non-stop “chanting” they did during some native rites but in these cases the possibility of malignancy is entertained by more experienced surgeons. Some nodules of long standing Nodular Goiter may develop “cancer” or may cause “hyperthyroidism”.
Simple goiter 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 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 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 likewise prescribed but this is strictly monitored because the patient may manifest “toxicity”. Hence the patient was advised a monthly follow-up which was immediately seconded by her granddaughter. From surgical textbooks, surgery for Simple Goiter is reserved for 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 grand son-in-law the patient refused surgery because anyway she lives in the mountains and is 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.
The surgeon promised that patients he encountered with thyroid malignancies and toxicity will also be presented soon in this column.
CITY HIGH FOUNDATION DAY
The Foundation Day of Baguio City National High School was recently corrected that instead of 1919, it was really 1916. The Centennial Year will be then next year so that preparation for its significance is getting full blast. The graduates of 1991 as well as of 1966 who will be the Silver and Golden Jubilarians next year respectively are just too happy that it coincided with their memorable celebrations. Dra. Elma D. Donaal, Ed. D., the hard working principal of the school who responded to our earlier column to correct us, created the team who really “painstakingly did the actual research” for the change and for such her team “were duly recognized and were given certificates for such effort”. Being the head of the school, it is obvious that she knows better. We summarize her letter.
In her letter she created a research committee headed by the late Head Teacher, Mrs. Evelyn Tadeo. The other members were the Panlipunan Teachers namely: Mrs. Saturnina Garcia, Mrs. Judica Dasco, Mr. Estelito Mendoza and Mrs. Tecla Padsoyan. They went to Trinidad Agricultural High School which is now the Benguet State University, Baguio City Library and the SLU and UP libraries. Their final research finding is summarized in the book of Laurence L. Wilson entitled Skyland of the Philippines which she quoted, “The first secondary school was the normal school at Baguio in 1916 which was later named Mt. Prov. High School. Its normal curriculum was transferred to Trinidad Agricultural High School in 1933 and it became Baguio City High School in 1937”.**
