The Vargas Case: Excision of Large Benign Goiter

November 12, 2011

Seventy-one-year-old Rose Vargas was diagnosed with chronic obstructive pulmonary disease (COPD) several years ago based on her increasing shortness of breath and diminished exercise capacity.

“I had never been sick before and suddenly, I couldn’t clean my house, walk the dog or babysit my grandchildren,” says Vargas, who has six children, seven grandchildren and three great-grandchildren.  “I was constantly out of breath, and in the end nothing was helping. I had all kinds of pumps and medications.  None of it provided any relief.”

Her condition worsened steadily over time.  In addition to physical incapacity, the disease took an emotional toll.  Constantly fatigued, the previously vivacious Vargas began to lose her joy for life.  When she failed to improve, her family became concerned about her frailty. Afraid that even a small amount of exertion might cause her to faint, they no longer allowed her to babysit her grandchildren or hold her great-grandchildren.

The week before Christmas 2010, she passed out at home. “I woke up around 4:30 in the morning and couldn’t breathe,” she remembers. “I told my husband I didn’t think I was going to make it.  I don’t remember anything at all after that until I woke up in the intensive care unit.”

Her husband dialed 911, and when the EMS team arrived, they intubated Vargas because she was unable to move air into and out of her lungs.  They transported her by ambulance to Clear Lake Regional Medical Center in Clear Lake, Texas, a community just south of Houston, where a chest x-ray and subsequent thoracic CT scan revealed a giant thyroid goiter that was filling the entire mediastinum, causing massive tracheal deviation and crush.  An emergency physician at the hospital did a trial extubation, which failed, and Vargas was reintubated.

“This was a very unusual case,” says Etan Weinstock, MD, an assistant professor in the The University of Texas Health Science Center at Houston (UTHealth) Department of Otorhinolaryngology, and a board-certified otorhinolaryngologist affiliated with Memorial Hermann-Texas Medical Center where Vargas was referred for further treatment.  “Typically, significant enlargement of the thyroid gland is visible to the eye, but she had no external sign of a goiter.  Instead, the gland had grown almost entirely into her chest.  This is extremely atypical of someone with a giant goiter.”

When routine blood work done on her arrival at Memorial Hermann-TMC revealed hyperthyroidism, Dr. Weinstock consulted with the hospital’s endocrine team to manage the disorder.  Surgery to excise the thyroid was originally scheduled for Christmas Day but postponed until December 27, when she was cleared for the procedure after correction of her hyperthyroid state.

“We decided the best approach was to attempt to excise the gland through the neck,” says Dr. Weinstock, who is also chief of otolaryngology-head and neck surgery at Lyndon B. Johnson Hospital in Houston.  “We also consulted with the Memorial Hermann/UTHealth cardiothoracic surgery team, who agreed to see Mrs. Vargas in advance and were available to assist in the event that excision through the neck proved impossible.”

Vargas says she had confidence in Dr. Weinstock from their first meeting.  “He was extremely thorough in his explanation of the surgery, which left me at peace.  God gave him a great gift of medical skill and in addition to that, he has a wonderful bedside manner. I had no fear.  All I wanted at that point was to get that tube out of my throat.”

Large goiters can cause multiple airway issues that may complicate surgery. “The trachea may be deviated by the enlarged gland, as it was in Mrs. Vargas’s case, which can make intubation challenging,” he says.  “She had been successfully intubated before her arrival here.  Had there been problems, we can generally readily accomplish fiberoptic intubation, but we discuss an airway management plan with the anesthesiologist in advance of any attempts.”

In a complex surgery, Dr. Weinstock succeeded in removing the entire enlarged thyroid gland through the neck.  “Fortunately, we were able to use the less-invasive approach, sparing her a sternotomy, as well as the longer recovery time associated with access through the chest,” he says.  “She had no postoperative complications, even those that you might expect with this kind of surgery, namely recurrent laryngeal nerve injury and voice weakness,” he says.  “We were able to successfully extubate her at the close of the procedure with a significantly improved airway.”

Vargas ate dinner the evening of her surgery and was discharged a few days later, without complications.  The pathology was benign, and after the incision healed, scarring was minimal.  No adjuvant therapies were required other than hormone replacement – typical after thyroidectomy.

She was back in action two weeks after her thyroidectomy.  “I was actually up and around three or four days after the surgery,” she says.  “I’m not a person to lie around on the bed.  Now, I can walk the dog, cook, clean and take care of my granddaughter. It’s a miracle to be able to breathe again.”

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