CASE PRESENTATION

STRUMA NODUSA

By :
Wina Hanriyani 1102012307

Preceptor :
Dr. HERRY SETYA YUDHA UTAMA, SpB, MHKes,FInaCS

Clinical Clerkship of Surgery Department

Faculty of Medicine YARSI University
RSUD Arjawinangun
December 2016
Case Presentation

I.

Identity
Name
Age
Gender
Tribe
Occupation
Address
In hospital since

: Ms. S
: 58 years old
: Female
: Javenese
: Gardener
: Kuningan
: December 8th 2016

II.

Anamnesis

Main Grievance

Additional Grievance

III.

: Lump in the neck

: Do not feel tightness and bumps elsewhere

Historical of Present Disease

A 58-year-old woman, came to the clinic and surgical Arjawinangun hospital with the

chief complaint there is a lump in the neck that are known about 5 years ago. Previous
lumps are small and do not complain of pain, the longer the lump growing.
Pain in the palpable lumps and bumps palpable hard, joined swallowing movements.
Complaints accompanied by heart palpitations and a hoarse voice.

IV.
V.

Historical of Past Disease

Patients had never performed the operation.
Diabetes mellitus (-),
Hypertension(-)
History of the head and neck radiation (-)
History drugs - thyroid drugs and drugs other long-term (-)
Historical of Family Disease

No family in the neighborhood of patients who have a complaint similar to the patient
VI.

Physical Examination

General Status

Present Status
General Condition
Awareness
Blood Pressure
Pulse
Breathing
Temperature

: Moderate
: Composmentis
: 140/90 mmHg
: 96 x/minute
: 24 x/minute
: 36,4 C

Head
Form
Hair
Eye

: Normal, Simetrical
: Black Colour, No hair fall
: Anemic Conjungtival -/-, Icteric Schlera -/-, Light Refleks (+), Isocorpupil

Ear
Nose
Mouth

right = left
: Normal form, cerumen (-), tympani membrane intac
: Normal form, No septum deviation, epitaction -/: Normal

Neck
Enlargement lymph nodes (-)
Trachea in the middle
palpable masses
Thoraks
Lungs - pulmonary
Inspection
: The chest shape is symmetrical both of left and right
Palpation
: Fremitus tactile and vocal symmetrical right and left, crepitus (-), tenderness
Percussion
Auscultation

(-), rebound tenderness (-)

: Sound of resonant in both lung fields
: Sound of vesicular and bronchial the entire lung field, ronkhi -/-, wheezing
-/-

Abdomen
Inspection
Palpation
Percussion
Auscultation
Extremity
Upper

: Normal
: Tenderness (-), rebound tenderness (-)
: Tympani
: Bowel (+)
: Muscle Tone
Movement
Mass
Strenght

normal
: active / active
:-/: 5/5
2

Lower

Genitalia

Edema
: Muscle Tone
Movement
Mass
Strenght
Edema
Swelling
: normal

:-/:normal
: active / active
:-/: 5/5
:-/:-/-

Status localist
At the regio colli
Inspection: visible mass in the neck front, the same color with the color
the skin around, rubor (-)
Palpation: mass palpable size 5,6 cm in teh neck. consistency a hard, flat surface, fixed to (+),
pain press (-), blood (-), Pus (-), tracheal deviation is difficult to assess.
Auscultation: bruit (-)
Laboratory Examination
Normal
Diagnosis
Struma Nudosa
Management
-

Inf RL 20 tts / min

Cefoperazon 2x1
tramadol 2x1
Ranitidine 2x1 amp
Surgical therapy
Operative plan thyroidectomy

Prognosis
Quo ad vitam
Quo ad fungsionam
Quo ad sanationam

VII.

: Dubia ad bonam
: Dubia ad bonam
: Dubia ad bonam

Literature Review

Goitre, nontoxic NODUSA

3

Struma nodosa is nontoxic struma nodosa without accompanying signs of hyperthyroidism.

Enlargement of the thyroid gland is not an inflammatory or neoplastic process and not
associated with thyroid function abnormalities.
Etiology
Struma nodosa nontoxic arise from the interaction of environmental, genetic and endogenous
factors. Some etiology is:
1.

Iodine deficiency iodine intake of less than 50 mcg / day. Iodine deficiency is the
most common cause of endemic and sporadic nontoxic goiter.

2.

excess iodine rare and usually occurs in patients with a previous history of
autoimmune thyroid disease.

3.

goitrogens:
- Medication: propilthiouracil (PTU), phenylbutazone, lithium, p-aminosalicylic acid,
aminoglutethimide, sulfonamides,
- Agent environment phenolic derivatives and Phtalate, resorcinol coal.
- Food vegetables (cabbage, cassava), seaweed.

4.Dishormogenesis

defect-derived thyroid hormone biosynthesis

5.history of head and neck radiation in childhood - childhood

6.Other risks factor: infection, emotional stress, smoking
Pathophysiology
The underlying growth of nodules on nodosa nontoxic goiter is the response of the thyroid
follicular cells are heterogeneous in the thyroid gland pad individuals. In a normal thyroid
gland, the sensitivity of the cells in the same follicle to the growth stimulus TSH and other
factors (IGF and EGF) varies widely. There is autonomous cells that can replicate without
TSH stimulation and the cells are very sensitive TSH faster replication. Cells will replicate to
produce cells with the same properties.
Follicular cell-cell functional activity varied greatly. The imbalance between the synthesis
and activity endositotik thyroglobulin this causes the growth of nodules varied.
Diagnosis

What needs to be considered in evaluating patients with non-toxic goitre is a goitre growth
patterns, symptoms of obstruction or compression and cosmetic complaints. There should
also be examined to assess the risk of malignancy.
anamnesis
-

Bumps on the anterior neck that grow slowly, not pain

A family history of thyroid disease
Enlargement of the thyroid during pregnancy
Complaints cosmetics
The existence of signs of compression and obstruction: hoarseness, stridor, shortness
of breath, difficult / painful swallowing, cough, symptoms of upper airway

obstruction.
Symptoms of hyperthyroidism may appear gradually
Symptoms of complications: bleeding pain caused by secondary, superior vena cava

syndrome and Horner's syndrome

History iodine diet

Physical examination
-

Evaluation of the thyroid gland: includes inspection, palpation and auscultation

Evaluation of signs of upper airway obstruction: dyspnoea, tracheal deviation, venous

obstruction
mark-mark thyroid dysfunction:
Hyperthyroidism: not resistant to high temperatures, increased appetite, weight loss,

palpitations, tachycardia, insomnia, tremor, exophthalmos, and squint.

Hypothyroidism: miksedem, constipation.
Usually not found lymphadenopathy

Malignancy rate
About 5% of struma nodosa undergo malignant degeneration. A careful history and
physical examination raise suspicion toward malignancy of thyroid:

Age <20 years or> 70 years

Gender male

Nodules with disfagi, hoarseness or airway obstruction

Pertumbuh nodules fast (a few weeks - months)

History radiation neck region when the child's age - child or adult (also increase the
incidence of benign thyroid nodules)

A family history of medullary thyroid cancer

Nodules are single, demarcated, hard, irregular and hard driven

Paralysis of the vocal cords

Findings cervical limpadenofati

Distant metastases (lung), ETC.

If clinically found signs of malignancy, thyroidectomy should be done even if

cytology showed a benign lesion.

Supporting investigation
1.
2.
3.
4.
5.

Tes thyroid function

thyroid
Skintigrafi thyroid
FNAB (Fine Needle Aspiration Biopsy)
Other investigations:
CT Scan or MRI solitary nodule or multiple nonhomogeneous
Pulmonary function tests disruption inspiration capacity

Here is the algorithm for the evaluation and management of thyroid nodules:

Figure 3. Algorithm evaluation and management of thyroid nodules.

Therapy
Struma nodosa nontoxic usually grows slowly and largely asymptomatic, so sometimes it
does not require therapy. Indications do therapy in nontoxic goiter is compressing the trachea
and esophagus, symptoms of venous obstruction, goitre progressive growth including
6

expansion into the chest cavity. Therapy is also indicated if there is a complaint of discomfort
in the neck and cosmetic complaints.
Therapy type
Surgery

profit
Significant reduction of goitre

Loss
risks of surgery

Decompression trachea quickly

Paralysis of the vocal cords (1%)

Eliminate the symptoms immediately -

Hypoparathyroidism (1%)

A definitive diagnosis

The risk of hypothyroidism due to

resection
-

Recurrence (depending on the type of

resection)

131

L-T4

Fewer subjective side effects

High cost
Limitations for the use of radioactive

Size reduction of 50% in one year

In

Improve the capacity of long-term

fertile

women

in

need

of

contraception

inspiration

Reduction of goitre growth slow

Can be repeated with good results

Risk of acute goitre enlargement

low Cost

(low)
-

Thyroiditis (3%)

Grave's disease (5%)

Hypothyroidism in the first year (15-

- Low cost

20%)
- Effectiveness Low

- To prevent the formation of nodules

- Treatment of a lifetime

new
- Reduction of 15- 40% in 3 months

- Adverse effects on bone and heart

- It can not be done if the low TSH

Surgical therapy
Goitre surgery can be divided into diagnostic surgery (biopsy) and therapeutic. Surgery in the
form of diagnostic incisional or excisional biopsy had been abandoned, especially after the
more accurate use of fine needle biopsy. Diagnostic biopsy is only done on the state of the
tumor can not be removed, such as in anaplastic carcinoma
A.

Follow-Surgical Indications Goitre, nontoxic:

Thyroidectomy is the treatment of choice in patients with young and healthy, especially in
cases requiring immediate decompression.
-

Cold nodules and solid.

Single nodule excision (which may be malignant)

Struma heavy multinoduler

7

Struma which causes compression of the larynx or other neck structures

Retrosternal goitre which causes compression of the trachea or other structures

Cosmetics (subtotal thyroidectomy)

B. complication Struma Surgery

1. During surgery:
- bleeding
- Recurrent nerve injury uni- or bilateral
- Injury to the trachea, esophagus, or nerves in the neck
- Tracheal collapse because Malasia trachea
- Lifting the entire parathyroid gland
- cutting duct in the neck torasiku right
2. Immediate postoperative:
- Bleeding in the neck
- Bleeding in the mediastinum
- Edema of the larynx
- Tracheal collapse
Thyroid crisis or thyrotoxicosis
3. A few hours-days pascabedahan:
- hematoma
- Wound infection
- Edema of the larynx
- Recurrent nerve paralysis
- Superior laryngeal nerve injury became apparent
- hypocalcemia
4. Old postoperative:
- hypothyroid
- Hipoparatiroid / hypocalcemia
- Recurrent nerve paralysis
- Superior laryngeal nerve injury
- Skin necrosis
- Thoracic duct leakage
Therapy post-surgery and prognosis
8

Nontoxic goitre recurrence seen in 15-40% of patients on long-term follow-up. Recurrence is

associated with postoperative residual tissue. Other factors are less influential are age,
duration of postoperative goitre and TSH levels. But with adequate surgery, recurrence rate of
no more than 10% within 10 years. Post-operative mortality rate is very low at less than 1%.

Bibliography
1. Hermus AR, Huysmans DA. Clinical manifestations and treatment of nontoxic diffuse
and nodular goiter. In: Braverman LE, Utiger RD, editors. The Thyroid. Philadelphia:
lippincot Williams & Wilkins, 2000. p. 866-70.
2. Lee S. Goiter, nontoxic. Available at: http //: www.emedicine.com.
3. Sjamsuhidajat R, Jong DW. Endocrine system. Textbook of Surgery, revised edition.
EGC 1997; 934-40
4. Hegedu LL, Bonnema SJ, Bennedbaek FN. Management of simple nodular goiter:
current status and future prespectives. USA: Endocrine reviews 24 (1): 102-132,
2003. Available at: http //: www.edrv-endojournals.org/pdf
5. MH Wheeler. The technique of thyroidectomy. JR Soc Med 1998; 91 (Suppl. 33) 1216. Available at: http //:www.pubmedcentral.nih.gov,
6. American Thyroid Association. Thyroid disease and pregnancy. Available at: http //:
www. thyroid.org.