By Tedler D. Depaynos, MD
The female patient is 47 years old school teacher who initially consulted their Municipal Health Officer (MHO) because of a “small mass” at the left side of her neck. It was non-tender but because it appeared to be gradually enlarging after several months by her constant palpation she began to worry.
The MHO gave the initial impression that the “small mass” at her cervical area was probably a lymph node due to her enlarged tonsils which was probably also the cause of her slightly hoarse voice. She was given Clindamycin 300 mg which was the only antibiotic available during that time in the Municipal Clinic and fortunately, it was free. She took it twice a day for 10 days.
After finishing her medications, there was a little improvement in her hoarse voice but her neck mass appeared to be the same. Actually, she thought that the hoarseness was just due to her shouting whenever she calls her husband who was a decade older and experiencing a difficulty in hearing. The improvement then was due to the control of her loud voice. She has been peeping on her tonsils from time to time and although they appear to be enlarged, they seem not to be inflamed. Nevertheless, she revisited their MHO who upon re-examination felt a small nodule at her left thyroid gland. He then changed his impression that it may be the cause of the cervical lymph node and the hoarse voice. From his experience, thyroid nodules causing hoarseness are usually malignant. A resulting metastatic lymph node may impinge on the recurrent laryngeal nerve which is responsible for the voice, hence, the hoarseness. He then referred her to a General Surgeon (GS) who used to be one of his professors and advised her to have an ultrasound (UTZ) of her anterior neck.
The UTZ confirmed the left thyroid nodule which is mainly solid and revealed several lymph nodes at her left neck. The GS then did a Fine Needle Biopsy (FNB) of the thyroid nodule and excised a left palpable cervical lymph node for biopsy and both have the same results, papilloma. Papilloma is the most common thyroid malignancy and because of the nodal metastasis, her condition is Stage 3. The surgeon, however, assured the patient that despite her Stage 3 condition, papilloma has a better prognosis than the other types of thyroid cancer.
Since the left thyroid mass by UTZ appear to be only 1 cm, part of the right thyroid gland might be left behind and a subtotal thyroidectomy would be done. Likewise, since the lymph nodes are more on the left, the neck dissection might be more concentrated on the left side. Of course, it would depend mainly on the operating surgeon and the findings during the surgery.
Although she was referred to a young Ear, Nose and Throat (ENT) specialist surgeon who had a very extensive training in modern neck surgery, she was cautioned by the GS that during the neck dissection the lymph node impinging on her recurrent laryngeal nerve would be removed, her voice might return to normal and if not, the hoarseness. hopefully,would not worsen. A subtotal thyroidectomy was preferred but if the surgeon would have no choice and would do a total thyroidectomy, she might experience hypothyroidism. Thyroid hormone replacement might be prescribed. Removal of all the malignant tissues was the main objective of the surgery, but if some might be left behind, she might undergo Iodine Radiation. This will all depend of course on the evaluation of the operating surgeon and the laboratory examinations of the removed tissues. Hence, she was advised to be uninhibited in inquiring from the ENT surgeon about her case.
The patient can then recall that although her mother died of “cardiac failure” she had a huge thyroid gland protruding at her anterior neck. Her problem perhaps was inherited but she would not like to be seen with a protruding thyroid gland especially in school so that she easily consented to the surgery.
It was months when the GS met the MHO who was once his student who mentioned that the patient apparently fully recovered. Her voice was obviously no longer hoarse because he saw her singing with the church choir one Sunday morning. She also went back to work. She is not with any medications but she was advised to visit her ENT surgeon from time to time for follow-up. **
