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Objectives: Compressive symptoms are common in thyroid disease; however, few studies have focused on the presence, associated factors, and etiology of compressive symptoms.Study Design: Retrospective chart review.Methods: Patients who underwent thyroidectomy by the Head and Neck Surgery Department at the Medical University of South Carolina (MUSC) from 2005 to the present were reviewed. The data included demographics, indication for surgery, compressive symptoms, complications, final diagnosis, volume and weight of thyroid gland, presence of inflammation, and follow-up.Results: Two hundred seventy patients were identified. The mean age was 51 years, 81% were female, and an average of 6 months of follow-up was obtained. The most common indications for surgery were atypical cells (42%) and goiter (37%). Forty-two percent (n = 112) of patients underwent hemithyroidectomy and 58% (n = 158) underwent total thyroidectomy. Fifty-two percent (n = 140) of patients experienced compressive symptoms preoperatively, including dysphagia (n = 107) and shortness of breath (n = 66). Twenty-eight percent (n = 76) of patients presented with voice changes, and 10% (n = 28) complained of odynophagia. Postoperatively, 22 patients (8%) continued to have compressive symptoms. The most common diagnoses associated with compressive symptoms were anaplastic thyroid cancer (75%), lymphocytic thyroiditis (74%), and goiter (60%). The average volume of the gland in patients with compressive symptoms was 78.4 mL compared to 39.6 mL in asymptomatic patients. There was not a significant relationship between compressive symptoms and the presence of inflammation.Conclusions: Patients with thyroid disease frequently present with compressive symptoms, and the majority of patients experience relief postoperatively. The volume of the thyroid gland is related to compressive symptoms, though other factors are involved.

Thyroid Disease and Compressive Symptoms

Caroline Banks, MD1; Christopher Ayers, MD1; Marion Boyd Gillespie, MD1

1Medical University of South Carolina, Department of Otolaryngology -- Head and Neck Surgery

Two hundred seventy patients were identified. The mean age was 51 years (SD = 16) and 81% (n = 219) were female. An average of 6 months of follow-up was obtained.

Forty-two percent (n = 112) of patients underwent hemithyroidectomy or completion thyroidectomy, and 58% (n = 158) of patients underwent total thyroidectomy. The most common indications for surgery were atypical or malignant cells (42%) and goiter or rapidly enlarging neck mass (37%).

Fifty-two percent (n = 140) of patients experienced compressive symptoms preoperatively, including dysphagia (n = 107), shortness of breath (n = 66), and compressive symptoms not otherwise specified (n = 32). Twenty-eight percent (n = 76) of patients presented with voice changes, and 10% (n = 28) of patients complained of odynophagia. Postoperatively, 8% (n = 22) of patients continued to have compressive symptoms. The most common diagnoses associated with compressive symptoms were anaplastic thyroid cancer (ATC) (75%), lymphocytic thyroiditis (74%), and goiter (60%). Odynophagia occurred in 21% (n = 4) of patients with thyroiditis, 20% (n = 2) of patients with Graves disease, and 15% (n = 4) of patients with follicular adenoma. Voice changes occurred in 100% (n = 2) of patients with medullary thyroid carcinoma (MTC), 63% (n = 5) of patients with ATC, and 42% (n = 8) of patients with thyroiditis (Table 1).

The average volume of the gland in patients with compressive symptoms undergoing hemithyroidectomy was 46.3 mL (SD = 59.4, range 0.4-308 mL) compared to 23.6 mL (SD = 39.4, range 0.6-304 mL) in asymptomatic patients. Patients with compressive symptoms whounderwent total thyroidectomy had an average gland volume of 96.8 mL (SD = 100.1, range 4-479 mL), compared to patients without compressive symptoms, who had an average gland volume of 56.6 mL (SD = 62.9, range 33-314) (Chart 1). Thirty-three percent (n = 28) of total thyroidectomy patients with compressive symptoms had markedly enlarged glands, compared to 23% (n = 14) of total thyroidectomy patients without compressive symptoms. There was not a significant relationship between compressive symptoms and the presence of inflammation.

Compressive symptoms are common in thyroid disease. The percent of patients with dysphagia or dyspnea is related to the type of thyroid disease. In our series, the overall incidence of compressive symptoms was 52%, and 60% of patients with benign multinodular goiter had symptoms of compression. On average, patients with dysphagia and/or shortness of breath had a larger volume of thyroid gland when compared to asymptomatic patients (78.4 mL vs. 39.6 mL).

Despite the relationship between gland size and compressive symptoms, not all patients with an enlarged thyroid gland develop compressive symptoms. Among patients with marked thyroid enlargement, 20% were asymptomatic with regards to compression.

There has been research to suggest that inflammation of the thyroid gland is related to compressive symptoms. In our study, the presence of inflammation among patients with compressive symptoms was not significantly different than the presence of inflammation in patients without compressive symptoms. However, 74% of patients with lymphocytic thyroiditis, an inflammatory condition, complained of dysphagia or shortness of breath. The incidence of compressive symptoms among those diagnosed with thyroiditis was second only to patients with ATC.

Multiple studies have demonstrated improvement or resolution of compressive symptoms after thyroid surgery. Thyroidectomy treated the symptoms of compression in 92% of patients in our study.

A retrospective chart review was performed on patients undergoing thyroidectomy at the Medical University of South Carolina (MUSC), Department of Otolaryngology – Head and Neck Surgery from 2005 to the present. Patients were identified through billing records using procedure codes for partial, total, and completion thyroidectomy. Exclusion criteria included patients under the age of 18 years, a diagnosis of squamous cell carcinoma, thyroidectomy for reasons other than thyroid disease, and patients with multiply recurrent thyroid cancer. Electronic medical records and archived paper charts were reviewed to obtain the following data: sex, age, race, indication for surgery, presence of neck mass, presence of compressive symptoms, postoperative complications, fine needle aspiration (FNA) result, final pathologic diagnosis, tumor size, volume and weight of thyroid gland, histologic presence of aggressive features, presence of inflammation, length of hospitalization, and follow-up. The volume of the thyroid gland was determined using the ellipsoid formula of p/6 multiplied by the height, width, and depth of each lobe.

This study represents a large series of patients with compressive symptoms secondary to thyroid disease. Though compressive symptoms, such as dysphagia and dyspnea, are common in thyroid disease, few studies have focused on the incidence, associated factors, and etiology of these symptoms. Our study reveals that, although the size of the gland contributes to compression, there are other factors, including inflammatory conditions, that are associated with the development of compressive symptoms. Future prospective studies are needed to determine the causation of compressive symptoms in thyroid disease.

Compressive symptoms are common among patients with thyroid disease and represent an indication for thyroidectomy [1,2]. Symptoms of compression range from mild, presenting with throat discomfort or globus sensation, to severe, involving significant dysphagia or dyspnea [3,4]. In rare cases, tracheal or esophageal compression lead to acute airway distress and require emergent treatment including intubation or tracheostomy [4,5].

Compressive symptomatology is associated with both benign and malignant thyroid disease [6]. Patients with multinodular goiter frequently complain of dysphagia or dyspnea [7]. Marked thyroid enlargement and substernal goiters have a higher incidence of compressive symptoms [1,5,8]. Though compressive symptoms are found in malignancy of the thyroid gland, the majority of patients presenting with aerodigestive compression will have benign thyroid disease [8]. Thyroidectomy is effective in relieving compressive symptoms [8,9].

Though diffuse thyroid enlargement is associated with tracheoesophageal compression, compressive symptoms are not exclusively related to the size of the thyroid gland. In addition to direct compression from an enlarged thyroid gland, dysphagia and shortness of breath may be a manifestation of thyrotoxicosis, Hashimoto’s thyroiditis, de Quervain’s thyroiditis, and other inflammatory diseases of the thyroid [10-14]. Studies indicate that inflammation of the thyroid gland is associated with compressive symptoms, however this has not been fully elucidated. This study explores the incidence of compressive symptoms in thyroid disease over a five-year period and describes associated factors and possible etiologies of compressive symptoms.

INTRODUCTION

METHODS AND MATERIALS

1. Lacoste L, Gineste D, Karayan J, Montaz N, Lehuede MS, Girault M, Bernit AF, Barbier J, Fusciardi J. Airway complications in thyroid surgery. Ann Otol Rhinol Laryngol 1993;102:441-6.

2. Greenblatt DY, Sippel R, Leverson G, Frydman J, Schaefer S, Chen H. Thyroid resection improves perception of swallowing function in patients with thyroid disease. World J Surg 2009;33:255-60.

3. Burns P, Timon C. Thyroid pathology and the globus symptom: are they related? A two year prospective trial. J Laryngol Otol 2007;121:242-5.

4. Alfonso A, Christoudias G, Amaruddin Q, Herbsman H, Gardner B. Tracheal or esophageal compression due to benign thyroid disease. Am J Surg 1981;142:350-4.

5. Shaha AR. Surgery for benign thyroid disease causing tracheoesophageal compression. Otolaryngol Clin North Am 1990;23:391-401.

6. Moumen M, Mehhane M, Kadiri B, Mawfik H, el Fares F. Compressive goiters. Apropos of 80 cases. J Chir (Paris) 1989;126:521-6.

7. Jauregui R, Lilker ES, Bayley A. Upper airway obstruction in euthyroid goiter. JAMA 1977;238:2163-6.8. McHenry CR, Piotrowski JJ. Thyroidectomy in patients with marked thyroid enlargement: airway

management, morbidity, and outcome. Am Surg;60:586-91.9. Maung KH, Hayworth D, Nix PA, Atkin SL, England RJ. Thyroidectomy dose not cause globus pattern

symptoms. J Laryngol Otol 2005;119:973-5.10. Mittendorf EA, McHenry CR. Thyroidectomy for selected patients with thyrotoxicosis. Arch Otolaryngol

Head Neck Surg 2001;127:61-5.11. Okada H, Yoshioka K. Thyrotoxicosis complicated with dysphagia. Intern Med 2009;48:1243-5.12. Guldiken B, Guldiken SS, Turgut N, Yuce M, Arikan E, Tugrul A. Dysphagia as a primary manifestation of

hyperthyroidism: a case report. Acta Clin Belg 2006;61:35-7.13. Duininck TM, van Heerden JA, Fatourechi V, Curlee KL, Farley DR, Thompson GB, Grant CS, Lloyd RV.

de Quervain’s thyroiditis: surgical experience. Endocr Pract 2002;8:255-8.14. Wang Z. Diagnosis and treatment in 45 patients with Hashimoto’s thyroiditis associated with throat

symptoms. Lin Chuang Er Bi Yan Hou Ke Za Zhi 2003;17:81-83.

CONCLUSIONS

DISCUSSIONRESULTS

REFERENCES

Chart 1. Volume of thyroid gland in patients with and without compressive symptoms.

ABSTRACT

Caroline Banks, MDMedical University of South CarolinaEmail: banksca@musc.edu

CONTACT

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Hemithyroidectomy Total Thyroidectomy

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Table 1. Diagnosis and associated symptoms.

PTC = papillary thyroid carcinoma; FTC = follicular thyroid carcinoma; ATC = anaplastic thyroid carcinoma; MTC = medullary thyroid carcinoma.

Other (17) 9(52.9) 4(23.5) 3(17.6)

MTC (2) 1(50) 0 2(100)

ATC (8) 6(75) 0 5(62.5)

Graves (10) 5(50) 2(20) 2(20)

FTC (10) 4(40) 0 1(10)

Thyroiditis (19) 14(73.7) 4(21.1) 8(42.1)

Follicular Adenoma (27) 12(44.4) 4(14.8) 9(33.3)

PTC (59) 18(30.5) 5(8.5%) 12(20.3)

Goiter (118) 71(60.2) 9(7.6) 33(28.0)

Diagnosis (n) n(%) n(%) n(%)

Compression Odynophagia Voice Changes