Unusual case of recurrent multinodular goitre causing severe tracheal compression in patient with active acromegaly.
Dr Sriranganath Akavarapu , Mr Neil Tolley, Dr Stephen Robinson
The association of acromegaly and thyroid enlargement is well recognised (65%). In practice the goitre is rarely large enough to cause significant compression of the surrounding structures.
We present a patient with a large partially intrathoracic multinodular goitre associated with acromegaly causing critical tracheal compression requiring multiple thyroidectomies.
A 57 year old lady presented to the combined thyroid clinic for a second opinion regarding tracheal compression due to a multinodular goitre. She had a subtotal thyroidectomy complicated by bilateral vocal cord palsy requiring tracheostomy 11 years previously. She had partial recovery of left vocal cord palsy but not right.
She represented with stridor and shortness of breath, repeat CT Neck showed MNG recurrence with very large left sided goitre causing severe tracheal compression to 6mm. On examination the endocrine registrar had felt the patient was clinically acromegalic, this being the first suggestion of the diagnosis. The OGTT showed failure to suppress GH with glucose load. The rest of her pituitary function was normal.
MRI Pituitary showed an expanded pituitary fossa with a thin rim of pituitary tissue within the sella and a thickened stalk indicating possible previous infarction of an adenoma. Formal Visual fields assessment was normal.
After discussion in the thyroid MDT meeting, she underwent completion thyroidectomy with major symptomatic improvement. There after she was treated with dopamine agonist initially with some improvement in biochemical markers but subsequently managed conservatively at her request. Follow up MRI showed static pituitary appearances.
Most Recent CT of neck showed no significant goitre recurrence but a 6mm trachea possibly related to previous tracheostomy precipitation tracheal stenosis.
Conclusion: This case demonstrates the benefits of a combined endocrine / surgical clinic and consideration of causes of recurrent multinodular goitre.