Thyroidectomy for Pain Alleviation in Hashimoto’s Thyroiditis: Case Report and Review of Literature
Corresponding Author: Mitali Dandekar, Department of Head Neck Surgery, Paras HMRI Hospital, Paras Healthcare, Patna, Bihar, India, Phone: +91 9820828189, e-mail: firstname.lastname@example.org
Received on: 20 December 2022; Accepted on: 30 January 2023; Published on: 08 June 2023
Introduction: Painful thyromegaly is a rare manifestation in Hashimoto’s thyroiditis. Management is conservative with surgery reserved for pain palliation. Challenges in surgery occur due to bouts of inflammation.
Case description: Middle-aged lady of Hashimoto’s thyroiditis with recurrent episodes of neck pain underwent total thyroidectomy for pain relief. There were no postoperative complications.
Discussion: Surgical outcomes for thyroiditis in literature are in retrospect on surgical specimen concomitant with primary diagnosis. This is a unique case reported about surgery for pain palliation. Authors discuss difficulties encountered in surgery and pointers to overcome them.
How to cite this article: Garg S, Sinha N, Ghosh R, et al. Thyroidectomy for Pain Alleviation in Hashimoto’s Thyroiditis: Case Report and Review of Literature. Int J Head Neck Surg 2023;14(2):33-35.
Source of support: Nil
Conflict of interest: None
Keywords: Hashimoto’s thyroiditis, Hypothyroidism, Thyroidectomy, Thyroiditis, Thyromegaly.
Lymphocytic thyroiditis or Hashimoto’s thyroiditis commonly occurs in middle-aged women.1 It presents as diffuse thyromegaly as well as alternating episodes of hypo- and hyperthyroidism, with hypothyroidism as the long-term sequel.2 Most patients are symptomatic for hypothyroidism apart from discomfort due to neck swelling, the majority of whom are treated conservatively. Thyroidectomy is occasionally performed when patients suffer from recurrent bouts of painful thyroiditis. However, surgery in such patients may be fraught with complications due to fibrosis from episodes of inflammation in thyroid.
Through this case report, the authors discuss the management of thyroiditis from a surgical perspective, along with a relevant literature review. Measures that can help achieve favorable outcomes are highlighted.
A 37-year-old female had complaints of long-standing thyroid swelling associated with bouts of pain and dysphagia of 1-month interval. She was diagnosed as Hashimoto’s thyroiditis with elevated antithyroid peroxidase antibody levels. She was on thyroid supplementation in view of hypothyroidism. On examination, firm, bulky, and enlarged bilateral thyroid lobes were palpable. However, no thyroid swelling was appreciated on inspection (Fig. 1). The thyroid was moving on deglutition and bilateral cords were mobile on Hopkins 70° endoscopy. Ultrasonography (USG) of the neck revealed multiple well-defined heterogeneous iso to hypoechoic lesions in both lobes, the largest of 1.5 cm in size. Diffusely enhanced vascularity was seen in thyroid. The lesion was classified as a thyroid imaging reporting and data systems III. USG-guided fine-needle aspiration cytology from the right lobe of the thyroid and isthmus showed the presence of florid lymphocytic thyroiditis (Hashimoto’s thyroiditis).
In view of frequent episodes of painful thyroiditis, a joint board of an endocrinologist and a surgeon discussed options of treatment with the patient between conservative management of acute symptoms vs thyroidectomy. The patient opted for surgery for permanent alleviation of symptoms. The patient had no comorbidities and had good performance status. Preoperatively, a contrast enhanced computed tomography scan of the neck and mediastinum was performed, which indicated diffusely enlarged lobes and isthmus of the thyroid gland with few tiny hypodense nodules within, along with subcentimetric lymphadenopathy.
An interval total thyroidectomy was performed 3 weeks after acute symptoms of thyroiditis had subsided and the hormone levels were normal on supplementation.
Intraoperatively, bilateral lobes of the thyroid were nodular with fibrosis around the thyroid gland and surrounding tissue (Fig. 2). A nerve integrity monitor was utilized to anticipate inflammation. Meticulous dissection with magnification was performed and bilateral parathyroids as well as nerves were preserved. Adequate signals on Intraoperative nerve monitoring confirmed nerve integrity.
Postoperatively, the patient had a normal voice. She developed biochemical hypocalcemia which was corrected with oral calcium and vitamin D supplementation. She was discharged on the 3rd postoperative day with calcium supplements which were tapered on follow-up. The patient had complete pain palliation.
Histopathology confirmed Hashimoto’s thyroiditis and showed atrophic follicles with extensive lymphocytic infiltration and multinucleated giant cells. The patient is asymptomatic and on follow-up with thyroxine supplementation.
Thyroiditis can occasionally be marked by episodes of pain at the site of inflammation along with painful deglutition.1 These symptoms subside once inflammation settles. Recurrent episodes lead to fibrosis, which makes surgery in this setting challenging and prone to complications. Literature review suggests an acceptable risk of surgery in patients with thyroiditis. Most studies, however, are in retrospect from histopathological specimens suggesting concomitant thyroiditis along with the primary pathology.3-6 Thus, the primary indication for surgery was either benign disease (goiter) or malignancy and not symptoms of painful thyroiditis. Needless to say, surgical outcomes in such patients cannot be extrapolated to our case since pain is a surrogate marker for inflammation with a potentially higher risk of complications.
A hypothesis has been proposed by Chiovato et al. indicating that the autoimmune response is attenuated if there is a complete removal of the antigenic tissue in autoimmune thyroiditis via total thyroidectomy.7 A randomized controlled trial of patients with symptomatic thyroiditis demonstrates encouraging results in favor of thyroidectomy, with respect to symptom relief.8 Of note though, these patients had exaggerated symptoms related to hypothyroidism (in spite of being biochemically euthyroid) and not related to local inflammation. Of 73 patients who were operated upon, complications were noted in 4.1% which included surgical infection, tracheal injury, and subcutaneous emphysema, 4.1% had permanent hypocalcemia, and 5.5% had recurrent nerve palsy. Although there were no reports of bleeding or hematoma, tracheal injury and subcutaneous emphysema are rare complications that could be attributed to fibrosis secondary to thyroiditis.
Episodes of painful thyroiditis are generally managed conservatively. Low-dose corticosteroids and nonsteroidal anti-inflammatory drugs help in reducing symptoms, especially in cases of subacute thyroiditis.9 Radioactive ablation has been attempted for permanent alleviation of symptoms, but results are variable.10
If surgery is considered for pain palliation, an interval thyroidectomy in which the patient is free of acute symptoms is recommended. Additionally, measures to aid in the preservation of recurrent laryngeal nerves like nerve integrity monitoring and the use of magnification for preserving parathyroid vasculature ensures favorable outcome.
Our patient had temporary biochemical hypocalcemia which was corrected with oral calcium supplementation.
This case is the first to report outcomes of thyroidectomy performed for pain palliation in Hashimoto’s thyroiditis.
Total thyroidectomy offers a permanent cure in patients with Hashimoto’s thyroiditis suffering from recurrent episodes of painful dysphagia. Although fraught with the risk of complications due to resultant fibrosis, surgical aids like nerve monitoring and magnification make surgery safer in this setting.
Written consent was obtained from the patient regarding the use of images from their CT scan and the reporting of this case.
Mitali Dandekar https://orcid.org/0000-0002-8435-4249
3. Gan X, Feng J, Deng X, et al. The significance of Hashimoto’s thyroiditis for postoperative complications of thyroid surgery: a systematic review and meta-analysis. Ann R Coll Surg Engl 2021;103(3):223–230. DOI: 10.1308/rcsann.2020.7013
5. Ravikumar K, Muthukumar S, Sadacharan D, et al. The impact of thyroiditis on morbidity and safety in patients undergoing total thyroidectomy. Indian J Endocrinol Metab 2018;22(4):494–498. DOI: 10.4103/ijem.IJEM_209_17
7. Chiovato L, Latrofa F, Braverman LE, et al. Disappearance of humoral thyroid autoimmunity after complete removal of thyroid antigens. Ann Intern Med 2003;139(5 Pt 1):346–351. DOI: 10.7326/0003-4819-139-5_part_1-200309020-00010
8. Guldvog I, Reitsma LC, Johnsen L, et al. Thyroidectomy versus medical management for euthyroid patients with hashimoto disease and persisting symptoms: a randomized trial. Ann Intern Med 2019;170(7):453–464. DOI: 10.7326/M18-0284
9. Sato J, Uchida T, Komiya K, et al. Comparison of the therapeutic effects of prednisolone and nonsteroidal anti-inflammatory drugs in patients with subacute thyroiditis. Endocrine 2017;55(1):209–214. DOI: 10.1007/s12020-016-1122-3
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