Surgical Management of Giant Bilateral Multinodular goiter with Significant Tracheal and Esophageal Outline distortion; A case report

Surgical Management of Giant Bilateral Multinodular goiter with Significant Tracheal and Esophageal Outline distortion; A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical Management of Giant Bilateral Multinodular goiter with Significant Tracheal and Esophageal Outline distortion; A case report Yohannes Teshome Kassie, Foad Adem Degu, Worku Awoke Terunehe, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8997704/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Giant goitre is a rare occurrence and is defined by an enlargement of the thyroid gland of at least 10 g/kg body weight or goiter weighing more than 500 grams or a thyroid tumour larger than 10 cm in diameter. Case presentation A 65 years old female patient who presented with anterior neck swelling with progressive size increment of about 30 years duration. She developed hot intolerance, palpitation and slight voice change for about 3 years. She has no remarkable medical, surgical history. On examination, she was tachycardic and had about 32*22cm very huge anterior neck swelling with visible multiple nodules grown more anterior to the sternum. On investigation, she had low TSH and high free T3 levels. Neck ultrasound shown multinodular thyroid enlargement with cystic and calcified components. Fine needle aspiration cytology was suggestive of benign colloid goiter. Lateral neck x ray shown significant anteriorly pulled trachea. She was put on antithyroid medication for about 3 years until the TFT was corrected and surgery was decided. Intraoperatively, there was about 34*22*7cm sized well encapsulated multinodular thyroid mass with anteriorly displaced trachea, esophagus, both recurrent laryngeal nerves and parthyroid glands. We did total thyroidectomy, preserved both recurrent laryngeal nerves and parathyroid glands. The mass weighed about 2350 grams , sent for histopathology later suggestive of benign colloid goiter. Clinical discussion Despite technical challenges, surgery continues to be the best option particularly in experienced hands due to its distinct advantage of immediate effect and complete resolution of compressive symptoms. The difficulty for this case was the anteriorly curved trachea and esophagus together with the recurrent nerves and parathyroid glands. Conclusion Thyroidectomy for giant goiters needs patience to preserve important structures with the assumption that a tired surgical team can have relief with rest but for the purpose of shortening surgery time, injuring recurrent laryngeal nerves or parathyroid glands do have lifelong sequela for the patient which never shouldn’t be the choice. Goiter Giant tracheal distortion case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction The normal adult thyroid gland weighs 10 to 25 grams. Goiter is an enlargement of thyroid gland due to compensatory hyperplasia and hypertrophy of the follicular epithelium which occurs sporadically [ 2 ]. Nodular goiter is rare before middle age and female preponderance has been established [ 2 ]. Giant goitre is a rare occurrence and is defined by an enlargement of the thyroid gland of at least 10 g/kg body weight or a thyroid tumour larger than 10 cm in diameter [ 1 ]. Occurrence of goitre in African settings has been widely reported and in Nigeria, some regions are described as goitrous zones or thyroid belt [ 1 ]. Toxic multinodular goiter (TMNG) usually occurs in older individuals, who often have a lengthy history of nontoxic multinodular goiter [ 3 ]. Over several years, enough thyroid nodules become autonomous to cause hyperthyroidism [ 2 ]. The development of multinodular goiter is thought to be due to persistent growth stimulation of the thyroid gland by thyroid-stimulating hormone during a period of inadequate production of thyroid hormones [ 4 ]. This stimulation leads to epithelial hyperplasia and then a diffuse goiter [ 4 ]. As a result of fluctuating stimulation, mixed areas that consist of active more hyperplastic and inactive focus ensue and nodular goiter usually occurs as an end stage of diffuse goiter [ 4 ]. Giant goiter weighing more than 500 grams can cause compression symptoms affecting the trachea, esophagus, and recurrent laryngeal nerve [ 1 , 3 ]. Nowadays, with the advent of daily use of iodized salt and increased awareness about the deficiency of iodine, the occurrence of large colloid goiters has become a rarity [ 5 ]. The clinical picture usually presents a slow evolution of an insidious character as the patient remains asymptomatic for a long period. When symptomatic, there may be dyspnea, dysphagia, dysphonia, hyperthyroidism, superior vena cava syndrome or any malignant transformation causing both local and distant symptoms and signs [ 6 ]. Patients should be investigated thoroughly for preoperative hormone assays to assess thyroid function and serum calcium to establish a reference value in the management of postoperative hypocalcemia. Imaging such as radiography, CT scan and magnetic resonance imaging (MRI) are useful for confirmation of thyroid location and extension (topography) of a goiter, and for detecting signs of compression or invasion of adjacent structures [ 7 , 8 ]. In advanced countries, virtual bronchoscopy using CT reconstruction is still important for preoperative evaluation and for planning the intubation approach and surgical strategy for the management of a potential stenosis or tracheal deviation [ 7 ]. Though several treatment modalities exist, surgical excision is preferred in patients with giant euthyroid goiters. This leads to immediate resolution of obstructive symptoms and restores the aesthetics of the patient’s neck [ 9 ]. Total thyroidectomy is the best treatment modality for giant goiters [ 2 , 3 , 9 , 10 ]. Methods The work has been reported in line with the SCARE criteria [ 11 ]. Case presentation A 65 years old female patient presented with anterior neck swelling with progressive size increment of about thirty (30) years duration. She developed hot intolerance, palpitation and slight voice change about three (3) years before her current presentation. Otherwise, she had no history of any known chronic medical illnesses, previous surgical history, breathing or swallowing difficulty and swelling to other sites. During physical examination at her initial presentation, her pulse rate was 96 beats per minute and all other vital signs were in normal range. She had about 32*22cm very huge anterior neck swelling with visible multiple nodules which grown more anterior to the sternum. The mass moves up with swallowing and the thyroid cartilage was palpable at the midline. There were no significantly engorged veins and Kocher’s manuever, Pemberton’s and Berry’s sign were all negative [Figure 1 ], [Figure 2 ], [Figure 3 ]. Other physical examination findings were unremarkable. She was then investigated with CBC, LFT and RFT which were all in normal range and her blood group was AB positive. Thyroid function test (TFT) shown low TSH and high free T3 levels. Neck ultrasound was suggestive of multinodular thyroid enlargement with cystic and calcified components with low suspicion for malignancy. Fine needle aspiration cytology (FNAC) taken from multiple nodules was suggestive of benign colloid goiter. ECG and echocardiography were normal. Lateral neck x ray shown significant anteriorly pulled trachea with multiple calcifications seen within the mass [Figure 4 ]. She was put on antithyroid medication (Propylthiouracil) and betablocker (Propranolol) for about three (3) years until the TFT was corrected. Otherwise, she claimed that the symptoms subsided in six months after initiation of therapy. After three years of follow up, her pulse rate was 76 beats per minute and the other physical examination findings were the same. CBC, RFT, LFT, TFT and ECG were all normal. Neck Ultrasound, neck x-ray and FNAC were also repeated and have similar findings as the initial one. Then, surgery was decided after informed and written consent was taken following thorough discussion about possible risks of recurrent laryngeal nerve injury, inadvertent injury or removal of parathyroid glands and its symptoms and possibility of tracheomalacia and tracheostomy in a way that the patient could understand. Intraoperatively, there was some difficulty of intubation due to anteriorly displaced trachea but it was successful with the help of video laryngoscope. The intraoperative finding was redundant skin and pretracheal fascia, atrophied strap muscles, about 34*22*7cm sized well encapsulated multinodular thyroid mass with anteriorly displaced trachea, esophagus, both recurrent laryngeal nerves and parthyroid glands. We did total thyroidectomy [Figure 5 ] and the surgery took about six (6) hours with all efforts expended to successfully preserve both recurrent laryngeal nerves and two grossly visible parathyroid glands. The tracheal cartilages were normal with no softening. The mass weighed about 2350 grams and it was sent for histopathology later suggestive of benign colloid goiter. The estimated blood loss was about 700ml and there was no need to transfuse her. Her post operative hematocrit determined after 10 hour after surgery was 33.2%. Postoperatively, she had normal voice with no signs of hypocalcemia or choking. She was discharged to home on the third day after surgery and appointed after a week [Figure 6 ], a month, three months and six months after surgery. She is on Levothyroxine supplementation and developed none of the possible surgical complications during her six months follow up. Discussion The challenges of managing giant goitre are magnified when seen in patients with significant socioeconomic concerns (indigent patients). These challenges are multi-directional, including some strain on the caregivers and drainage of resources from the health system administrators’ perspective [ 1 ]. Our patient had similar challenges as poor socioeconomic support and inadequate awareness and preferred to hide her condition for all those years than seeking medical care early. Worldwide, the most common cause of goiter is iodine deficiency. In fact, it has been estimated that goiters affect as many as 200 million of the 800 million people who have a diet deficient in iodine [ 1 , 3 , 4 , 9 ]. Our patient is a farmer who lives in a highland area which could predispose her for iodine deficiency at her earlier age due to washed out iodine content of the soil making the crops grown there to be iodine deficient. Giant thyroid tumor is rare and defined as any thyroid tumor with an average weight greater than 500 g or 10 g/kg body weight or diameter greater than 100 mm [ 1 , 4 ]. Most patients present with huge goiter with compressive symptoms like dyspnea and dysphagia associated with symptoms and signs of hyperthyroidism but extrathyroidal manifestations are absent unlike Graves’ disease [ 3 ]. Because of its location, a massive goiter is unsightly and could severely affect the patency of the trachea and esophagus, which can be a potentially life-threatening condition [ 4 ]. This case is one of the the few extremely large goiters but without any of the compressive symptoms other than the hyperthyroidism and minimal voice changes likely due to anteriorly pulled recurrent laryngeal nerves together with the trachea and esophagus. Those patients with goiter should undergo TFT (T3, T4, TSH) measurement, ultrasound of the neck and FNAC as a diagnostic modality. A neck x-ray and CT scan can be done when the patient is diagnosed with a giant goiter [ 2 , 3 , 5 , 6 ]. We investigated our patient with CBC, TFT, LFT, RFT, ECG, neck ultrasound and neck x-ray but she was not able to afford contrast enhanced neck CT scan. In spite of the technical challenge, surgery continues to be the best option particularly in experienced hands due to its distinct advantage of immediate effect and complete resolution of compressive symptoms [ 8 ]. For a long while, many surgeons practice Sub-total thyroidectomy, which involves removal of both thyroid lobes and isthmus, leaving behind only about 8g on both sides [ 9 ]. This preserves some thyroid tissue just enough to sustain the adequate hormone levels and not too much to prevent recurrence [ 1 , 2 , 4 , 5 ]. With total thyroidectomy, there are no chances of recurrence with this technique, however, the risk of loss of the parathyroids, the need for lifelong L-thyroxine, and the risk of damage to both recurrent laryngeal nerves makes some surgeons to prefer sub-total thyroidectomy instead [ 9 , 10 ]. The identification of recurrent laryngeal nerve (RLN) and parathyroid glands is accepted by most authors [ 2 , 3 , 4 , 6 ]. Special surgical techniques, for example, capsular dissection technique and neuromonitoring, may further improve the results of surgery and avoid complications [ 5 ]. After we achieved an euthyroid state for our patient, we decided to do total thyroidectomy after detail explanation of possible risks surgery to the patient and her attendants. Intraoperatively, despite the absence of neuromonitoring in our setup, we took time to identify and not to injure both recurrent laryngeal nerves and not to remove or devascularize the identified parathyroid glands. The significant challenge was the anteriorly curved trachea and esophagus together with the recurrent nerves and parathyroid glands. In postoperative period, each practitioner needs to assess predisposing risk for occurrence of post thyroidectomy tracheomalacia include large goiters of long duration older than five years and large size as in our case, malignancy goiters or re-do thyroidectomy, preoperative recurrent laryngeal nerve paralysis, significant narrowing and/or deviation of the trachea, retrosternal or retrotracheal extension and difficult tracheal intubation [ 7 ]. We were lucky enough that non of the possible complications (nerve injury, hypocalcemia and tracheomalacia) didn’t happened except the lifelong thyroxine supplementation for we couldn’ find any healthy thyroid tissue to be preserved. Conclusion Even if the surgical techniques used could be routine, the operative difficulty is the large size of the gland and distortion of anatomical landmarks. To perform an effective and safe surgery, careful preoperative preparation, teamwork and appropriate evaluation of the extent of the goiter and airway status are important. Thyroidectomy for such giant goiters needs patience for careful dissection and preserve important structures with the assumption that a tired surgical team can have relief with rest but for the purpose of shortening surgery time, injuring recurrent laryngeal nerves or parathyroid glands do have lifelong sequela for the patient which should never be the choice. Abbreviations CBC: Complete blood count; cm: Centimeter; CT: Computerized Tomography; ECG: Electrocardiography; FNAC: Fine needle aspiration cytology; g: grams; kg: Kilograms;LFT: Liver function test; MRI: Magnetic resonance imaging; RFT: Renal function test; RLN: Recurrent laryngeal nerve; SCARE; Surgical case reports: T3: Triiodothyronine; T4: Tetra iodothyronine; TFT: Thyroid function test; TMNG: Toxic multinodular goiter; TSH: Thyroid stimulating hormone; WMA: World medical association: Declarations Ethical approval Based on declaration of Helsinki developed by The World Medical Association (WMA), Ethical Review Committee of Wollo University approved the ethical issue of this study and official permission to undertake the study was obtained from Institutional review board (IRB) of the same University. The confidentiality and privacy of patients was maintained during data collection. Consent for publication Informed consent was obtained from the patient for this study because this is a low risk study and the patient can’t read and write for which the authors agreed not to put fingerprint as signature for confidentiality purposes. Consent to Participate statement Informed consent was obtained from the patient for participation in this study. Competing interests Authors declare that they have no competing interests. Funding The authors received no financial support for the publication and/or authorship of this article. Author Contribution Conceptualization: YT. Data collection and Methodology development: YT. Data analysis: YT, FA, WA, SL, YK. Manuscript Draft: YT, AF. Manuscript review and editing; YT, AF, FA, WA, SL, YK. All authors have read and approved the manuscript. Acknowledgements Not applicable. Data Availability The datasets used and/or analyzed during the current study are available from corresponding authors on reasonable request. 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Leivaditis V, Liolis E, Baltayiannis N, Sarof P, Pagoulatou A, Grapatsas K, Antzoulas A, Litsas D, Papadopoulos PD, Theofanis G, Nikolakopoulos K. Diving retrosternal goiter and the dilemma of sternotomy: indications, predictors and surgical considerations. Kardiochirurgia i Torakochirurgia Polska/Polish J Thorac Cardiovasc Surg. 2025;22(3):174–81. Razafimanjato NN, Ravelomihary TD, Tsiambanizafy GO, Rakotovao HJ, Rajaonera AT. Surgery and anesthesiological approach for giant thyroid goiter: an unusual case of didactic management. Thyroid Disorders Ther. 2020;9:237. Machado NO. Thyroidectomy for massive goiter weighing more than 500 grams. technical difficulties, complications and management. review. Surg Sci. 2011;2(5):278. Aliyu D, Iseh KR, Semen YS, Amutta SB, Solomon JH, Adeyeye FM. Giant Euthyroid Goitre: Clinical Profile as Seen in Otorhinolaryngology Department of a Tertiary Health Institution, in Northwestern Nigeria. J Adv Med Med Res. 2019;30(4):1–9. Lame CA, Atila M, Dembele B, Obeng MK, Atila Sr LAMECA, Dembele Sr M. B. Management of a long-standing huge goiter during a humanitarian mission: a case report. Cureus. 2023;15(5). Kerwan A, Al-Jabir A, Mathew G, Sohrabi C, Rashid R, Franchi T, Nicola M, Agha M, Agha RA. Revised Surgical CAse REport (SCARE) guideline: An update for the age of Artificial Intelligence. Premier J Sci 2025:10100079. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Mar, 2026 Reviews received at journal 16 Mar, 2026 Reviews received at journal 15 Mar, 2026 Reviews received at journal 15 Mar, 2026 Reviewers agreed at journal 15 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers invited by journal 12 Mar, 2026 Editor invited by journal 10 Mar, 2026 Editor assigned by journal 04 Mar, 2026 Submission checks completed at journal 04 Mar, 2026 First submitted to journal 28 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8997704","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":598631915,"identity":"6c719c3d-4098-44b7-9038-e3a41aed75fb","order_by":0,"name":"Yohannes Teshome 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patient's neck (Anterior view)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8997704/v1/b4e9596a47b2fc234dcf7a93.jpg"},{"id":104177113,"identity":"7f8ee62e-72f1-4c44-8322-34ba531ea3d9","added_by":"auto","created_at":"2026-03-08 16:43:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":140056,"visible":true,"origin":"","legend":"\u003cp\u003ePre-operative Picture of the patient's neck (Right lateral view)\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8997704/v1/5fb6f777a2ca64c8b358d06f.jpg"},{"id":104404267,"identity":"47fdb608-0ca4-4387-a000-9d219c28e84e","added_by":"auto","created_at":"2026-03-11 12:19:57","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":152578,"visible":true,"origin":"","legend":"\u003cp\u003ePre-operative Picture of the patient's neck (Left lateral view)\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8997704/v1/625f085339a51294ec0a0486.jpg"},{"id":104404755,"identity":"9970c16a-c8be-441c-9895-910501978115","added_by":"auto","created_at":"2026-03-11 12:21:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":550765,"visible":true,"origin":"","legend":"\u003cp\u003eNeck x-ray with Anterior view (A) and Lateral view (B) showing significant anteriorly pulled trachea with multiple calcifications seen within the mass.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8997704/v1/586c4019d88e8c28fc5ec3b0.png"},{"id":104177110,"identity":"e007afcf-ace4-4334-b8af-bc2ca759a613","added_by":"auto","created_at":"2026-03-08 16:43:45","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":879559,"visible":true,"origin":"","legend":"\u003cp\u003eThe thyroid mass after removal; Anterior view (A) and Posterior view (B)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8997704/v1/695a42d2e374f94b3b2a4853.png"},{"id":104177112,"identity":"a3d18573-ccea-41b7-b3f3-3f973b6c027d","added_by":"auto","created_at":"2026-03-08 16:43:45","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":163320,"visible":true,"origin":"","legend":"\u003cp\u003eThe wound on the patient's neck after one week\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8997704/v1/c7f9c2175baecc0b771334bc.png"},{"id":104409101,"identity":"f30958b9-640f-420c-ab7f-257344c767e4","added_by":"auto","created_at":"2026-03-11 12:44:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3343057,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8997704/v1/026c9dbe-70d9-4c42-8fb7-f9d4285c968d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Management of Giant Bilateral Multinodular goiter with Significant Tracheal and Esophageal Outline distortion; A case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe normal adult thyroid gland weighs 10 to 25 grams. Goiter is an enlargement of thyroid gland due to compensatory hyperplasia and hypertrophy of the follicular epithelium which occurs sporadically [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Nodular goiter is rare before middle age and female preponderance has been established [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Giant goitre is a rare occurrence and is defined by an enlargement of the thyroid gland of at least 10 g/kg body weight or a thyroid tumour larger than 10 cm in diameter [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Occurrence of goitre in African settings has been widely reported and in Nigeria, some regions are described as goitrous zones or thyroid belt [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eToxic multinodular goiter (TMNG) usually occurs in older individuals, who often have a lengthy history of nontoxic multinodular goiter [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Over several years, enough thyroid nodules become autonomous to cause hyperthyroidism [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The development of multinodular goiter is thought to be due to persistent growth stimulation of the thyroid gland by thyroid-stimulating hormone during a period of inadequate production of thyroid hormones [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This stimulation leads to epithelial hyperplasia and then a diffuse goiter [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As a result of fluctuating stimulation, mixed areas that consist of active more hyperplastic and inactive focus ensue and nodular goiter usually occurs as an end stage of diffuse goiter [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiant goiter weighing more than 500 grams can cause compression symptoms affecting the trachea, esophagus, and recurrent laryngeal nerve [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Nowadays, with the advent of daily use of iodized salt and increased awareness about the deficiency of iodine, the occurrence of large colloid goiters has become a rarity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The clinical picture usually presents a slow evolution of an insidious character as the patient remains asymptomatic for a long period. When symptomatic, there may be dyspnea, dysphagia, dysphonia, hyperthyroidism, superior vena cava syndrome or any malignant transformation causing both local and distant symptoms and signs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients should be investigated thoroughly for preoperative hormone assays to assess thyroid function and serum calcium to establish a reference value in the management of postoperative hypocalcemia. Imaging such as radiography, CT scan and magnetic resonance imaging (MRI) are useful for confirmation of thyroid location and extension (topography) of a goiter, and for detecting signs of compression or invasion of adjacent structures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In advanced countries, virtual bronchoscopy using CT reconstruction is still important for preoperative evaluation and for planning the intubation approach and surgical strategy for the management of a potential stenosis or tracheal deviation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThough several treatment modalities exist, surgical excision is preferred in patients with giant euthyroid goiters. This leads to immediate resolution of obstructive symptoms and restores the aesthetics of the patient\u0026rsquo;s neck [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Total thyroidectomy is the best treatment modality for giant goiters [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe work has been reported in line with the SCARE criteria [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e "},{"header":"Case presentation","content":"\u003cp\u003eA 65 years old female patient presented with anterior neck swelling with progressive size increment of about thirty (30) years duration. She developed hot intolerance, palpitation and slight voice change about three (3) years before her current presentation. Otherwise, she had no history of any known chronic medical illnesses, previous surgical history, breathing or swallowing difficulty and swelling to other sites. During physical examination at her initial presentation, her pulse rate was 96 beats per minute and all other vital signs were in normal range. She had about 32*22cm very huge anterior neck swelling with visible multiple nodules which grown more anterior to the sternum. The mass moves up with swallowing and the thyroid cartilage was palpable at the midline. There were no significantly engorged veins and Kocher’s manuever, Pemberton’s and Berry’s sign were all negative [Figure \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e], [Figure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e], [Figure \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e]. Other physical examination findings were unremarkable.\u003c/p\u003e\u003cp\u003eShe was then investigated with CBC, LFT and RFT which were all in normal range and her blood group was AB positive. Thyroid function test (TFT) shown low TSH and high free T3 levels. Neck ultrasound was suggestive of multinodular thyroid enlargement with cystic and calcified components with low suspicion for malignancy. Fine needle aspiration cytology (FNAC) taken from multiple nodules was suggestive of benign colloid goiter. ECG and echocardiography were normal. Lateral neck x ray shown significant anteriorly pulled trachea with multiple calcifications seen within the mass [Figure \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eShe was put on antithyroid medication (Propylthiouracil) and betablocker (Propranolol) for about three (3) years until the TFT was corrected. Otherwise, she claimed that the symptoms subsided in six months after initiation of therapy.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cp\u003eAfter three years of follow up, her pulse rate was 76 beats per minute and the other physical examination findings were the same. CBC, RFT, LFT, TFT and ECG were all normal. Neck Ultrasound, neck x-ray and FNAC were also repeated and have similar findings as the initial one. Then, surgery was decided after informed and written consent was taken following thorough discussion about possible risks of recurrent laryngeal nerve injury, inadvertent injury or removal of parathyroid glands and its symptoms and possibility of tracheomalacia and tracheostomy in a way that the patient could understand.\u003c/p\u003e\u003cp\u003eIntraoperatively, there was some difficulty of intubation due to anteriorly displaced trachea but it was successful with the help of video laryngoscope. The intraoperative finding was redundant skin and pretracheal fascia, atrophied strap muscles, about 34*22*7cm sized well encapsulated multinodular thyroid mass with anteriorly displaced trachea, esophagus, both recurrent laryngeal nerves and parthyroid glands. We did total thyroidectomy [Figure \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e] and the surgery took about six (6) hours with all efforts expended to successfully preserve both recurrent laryngeal nerves and two grossly visible parathyroid glands. The tracheal cartilages were normal with no softening. The mass weighed about 2350 grams and it was sent for histopathology later suggestive of benign colloid goiter. The estimated blood loss was about 700ml and there was no need to transfuse her. Her post operative hematocrit determined after 10 hour after surgery was 33.2%.\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cp\u003ePostoperatively, she had normal voice with no signs of hypocalcemia or choking. She was discharged to home on the third day after surgery and appointed after a week [Figure \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e], a month, three months and six months after surgery. She is on Levothyroxine supplementation and developed none of the possible surgical complications during her six months follow up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe challenges of managing giant goitre are magnified when seen in patients with significant socioeconomic concerns (indigent patients). These challenges are multi-directional, including some strain on the caregivers and drainage of resources from the health system administrators\u0026rsquo;\u003c/p\u003e \u003cp\u003eperspective [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Our patient had similar challenges as poor socioeconomic support and inadequate awareness and preferred to hide her condition for all those years than seeking medical care early.\u003c/p\u003e \u003cp\u003eWorldwide, the most common cause of goiter is iodine deficiency. In fact, it has been estimated that goiters affect as many as 200\u0026nbsp;million of the 800\u0026nbsp;million people who have a diet deficient in iodine [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Our patient is a farmer who lives in a highland area which could predispose her for iodine deficiency at her earlier age due to washed out iodine content of the soil making the crops grown there to be iodine deficient.\u003c/p\u003e \u003cp\u003eGiant thyroid tumor is rare and defined as any thyroid tumor with an average weight greater than 500 g or 10 g/kg body weight or diameter greater than 100 mm [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Most patients present with huge goiter with compressive symptoms like dyspnea and dysphagia associated with symptoms and signs of hyperthyroidism but extrathyroidal manifestations are absent unlike Graves\u0026rsquo; disease [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because of its location, a massive goiter is unsightly and could severely affect the patency of the trachea and esophagus, which can be a potentially life-threatening condition [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This case is one of the the few extremely large goiters but without any of the compressive symptoms other than the hyperthyroidism and minimal voice changes likely due to anteriorly pulled recurrent laryngeal nerves together with the trachea and esophagus.\u003c/p\u003e \u003cp\u003eThose patients with goiter should undergo TFT (T3, T4, TSH) measurement, ultrasound of the neck and FNAC as a diagnostic modality. A neck x-ray and CT scan can be done when the patient is diagnosed with a giant goiter [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. We investigated our patient with CBC, TFT, LFT, RFT, ECG, neck ultrasound and neck x-ray but she was not able to afford contrast enhanced neck CT scan.\u003c/p\u003e \u003cp\u003eIn spite of the technical challenge, surgery continues to be the best option particularly in experienced hands due to its distinct advantage of immediate effect and complete resolution of compressive symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For a long while, many surgeons practice Sub-total thyroidectomy, which involves removal of both thyroid lobes and isthmus, leaving behind only about 8g on both sides [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This preserves some thyroid tissue just enough to sustain the adequate hormone levels and not too much to prevent recurrence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. With total thyroidectomy, there are no chances of recurrence with this technique, however, the risk of loss of the parathyroids, the need for lifelong L-thyroxine, and the risk of damage to both recurrent laryngeal nerves makes some surgeons to prefer sub-total thyroidectomy instead [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The identification of recurrent laryngeal nerve (RLN) and parathyroid glands is accepted by most authors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Special surgical techniques, for example, capsular dissection technique and neuromonitoring, may further improve the results of surgery and avoid complications [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. After we achieved an euthyroid state for our patient, we decided to do total thyroidectomy after detail explanation of possible risks surgery to the patient and her attendants. Intraoperatively, despite the absence of neuromonitoring in our setup, we took time to identify and not to injure both recurrent laryngeal nerves and not to remove or devascularize the identified parathyroid glands. \u003cb\u003eThe significant challenge was the anteriorly curved trachea and esophagus together with the recurrent nerves and parathyroid glands.\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn postoperative period, each practitioner needs to assess predisposing risk for occurrence of post thyroidectomy tracheomalacia include large goiters of long duration older than five years and large size as in our case, malignancy goiters or re-do thyroidectomy, preoperative recurrent laryngeal nerve paralysis, significant narrowing and/or deviation of the trachea, retrosternal or retrotracheal extension and difficult tracheal intubation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. We were lucky enough that non of the possible complications (nerve injury, hypocalcemia and tracheomalacia) didn\u0026rsquo;t happened except the lifelong thyroxine supplementation for we couldn\u0026rsquo; find any healthy thyroid tissue to be preserved.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEven if the surgical techniques used could be routine, the operative difficulty is the large size of the gland and distortion of anatomical landmarks. To perform an effective and safe surgery, careful preoperative preparation, teamwork and appropriate evaluation of the extent of the goiter and airway status are important. Thyroidectomy for such giant goiters needs patience for careful dissection and preserve important structures with the assumption that \u003cb\u003ea tired surgical team can have relief with rest but for the purpose of shortening surgery time, injuring recurrent laryngeal nerves or parathyroid glands do have lifelong sequela for the patient which should never be the choice.\u003c/b\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBC: Complete blood count; cm: Centimeter; CT: Computerized Tomography; ECG: Electrocardiography; FNAC: Fine needle aspiration cytology; g: grams; kg: Kilograms;LFT: Liver function test; MRI: Magnetic resonance imaging; RFT: Renal function test; RLN: Recurrent laryngeal nerve; SCARE; Surgical case reports: T3: Triiodothyronine; T4: Tetra iodothyronine; TFT: Thyroid function test; TMNG: Toxic multinodular goiter; TSH: Thyroid stimulating hormone; WMA: World medical association:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eBased on declaration of Helsinki developed by The World Medical Association (WMA), Ethical Review Committee of Wollo University approved the ethical issue of this study and official permission to undertake the study was obtained from Institutional review board (IRB) of the same University. The confidentiality and privacy of patients was maintained during data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient for this study because this is a low risk study and the patient can\u0026rsquo;t read and write for which the authors agreed not to put fingerprint as signature for confidentiality purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003estatement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent\u0026nbsp;was obtained from the patient for participation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe authors received no financial support for the publication and/or authorship of this article.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualization: YT. Data collection and Methodology development: YT. Data analysis: YT, FA, WA, SL, YK. Manuscript Draft: YT, AF. Manuscript review and editing; YT, AF, FA, WA, SL, YK. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from corresponding authors on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIjah RF, Wakama IE, Gbobo I, Green IA. An unusual giant recurrent goiter: A case report and literature review. Afr J Res Med Health Sci. 2024;2(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJason NK, Akomu M, Safari S, Sosthene TV, Namwagala J. Management of a giant euthyroid goiter in limited resources settings: Case report. Int J Otorhinolaryngol Head Neck Surg. 2020;6(3):574.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaeme G, Tibebu Shumargaw M. Surgical management of giant toxic multinodular goiter with compressive symptoms in setup with scarce resources: a case report. Open Access Surg. 2022 Dec;31:101\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTola GG, Tesso BA, Shale WT. A giant toxic multinodular goiter extending into the retropharyngeal space: A case report. Int J Surg Case Rep. 2023;109:108543.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudhiraja G, Dhingra HS, Guram D, Goyal S, Bharti P. An unusual presentation of large colloid goiter\u0026ndash;A case report. Adesh Univ J Med Sci Res. 2020;2(1):64\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeivaditis V, Liolis E, Baltayiannis N, Sarof P, Pagoulatou A, Grapatsas K, Antzoulas A, Litsas D, Papadopoulos PD, Theofanis G, Nikolakopoulos K. Diving retrosternal goiter and the dilemma of sternotomy: indications, predictors and surgical considerations. Kardiochirurgia i Torakochirurgia Polska/Polish J Thorac Cardiovasc Surg. 2025;22(3):174\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRazafimanjato NN, Ravelomihary TD, Tsiambanizafy GO, Rakotovao HJ, Rajaonera AT. Surgery and anesthesiological approach for giant thyroid goiter: an unusual case of didactic management. Thyroid Disorders Ther. 2020;9:237.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMachado NO. Thyroidectomy for massive goiter weighing more than 500 grams. technical difficulties, complications and management. review. Surg Sci. 2011;2(5):278.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAliyu D, Iseh KR, Semen YS, Amutta SB, Solomon JH, Adeyeye FM. Giant Euthyroid Goitre: Clinical Profile as Seen in Otorhinolaryngology Department of a Tertiary Health Institution, in Northwestern Nigeria. J Adv Med Med Res. 2019;30(4):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLame CA, Atila M, Dembele B, Obeng MK, Atila Sr LAMECA, Dembele Sr M. B. Management of a long-standing huge goiter during a humanitarian mission: a case report. Cureus. 2023;15(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKerwan A, Al-Jabir A, Mathew G, Sohrabi C, Rashid R, Franchi T, Nicola M, Agha M, Agha RA. Revised Surgical CAse REport (SCARE) guideline: An update for the age of Artificial Intelligence. Premier J Sci 2025:10100079.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Goiter, Giant, tracheal distortion, case report","lastPublishedDoi":"10.21203/rs.3.rs-8997704/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8997704/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiant goitre is a rare occurrence and is defined by an enlargement of the thyroid gland of at least 10 g/kg body weight or goiter weighing more than 500 grams or a thyroid tumour larger than 10 cm in diameter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 65 years old female patient who presented with anterior neck swelling with progressive size increment of about 30 years duration. She developed hot intolerance, palpitation and slight voice change for about 3 years. She has no remarkable medical, surgical history. On examination, she was tachycardic and had about 32*22cm very huge anterior neck swelling with visible multiple nodules grown more anterior to the sternum. On investigation, she had low TSH and high free T3 levels. Neck ultrasound shown multinodular thyroid enlargement with cystic and calcified components. Fine needle aspiration cytology was suggestive of benign colloid goiter. Lateral neck x ray shown significant anteriorly pulled trachea. She was put on antithyroid medication for about 3 years until the TFT was corrected and surgery was decided. Intraoperatively, there was about 34*22*7cm sized well encapsulated multinodular thyroid mass with anteriorly displaced trachea, esophagus, both recurrent laryngeal nerves and parthyroid glands. We did total thyroidectomy, preserved both recurrent laryngeal nerves and parathyroid glands. The mass weighed about \u003cstrong\u003e2350 grams\u003c/strong\u003e, sent for histopathology later suggestive of benign colloid goiter.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical discussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite technical challenges, surgery continues to be the best option particularly in experienced hands due to its distinct advantage of immediate effect and complete resolution of compressive symptoms. \u003cstrong\u003eThe difficulty for this case was the anteriorly curved trachea and esophagus together with the recurrent nerves and parathyroid glands.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThyroidectomy for giant goiters needs patience to preserve important structures with the assumption that a tired surgical team can have relief with rest but for the purpose of shortening surgery time, injuring recurrent laryngeal nerves or parathyroid glands do have lifelong sequela for the patient which never shouldn’t be the choice.\u003c/p\u003e","manuscriptTitle":"Surgical Management of Giant Bilateral Multinodular goiter with Significant Tracheal and Esophageal Outline distortion; A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 16:43:37","doi":"10.21203/rs.3.rs-8997704/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-16T08:18:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T06:01:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T09:42:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T06:52:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59126026166327907940507702487218072323","date":"2026-03-15T05:40:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"192537608380020477896472152935416602432","date":"2026-03-14T05:33:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98979101959411699776888307394563040068","date":"2026-03-14T03:41:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224277822196437887224228614086294841006","date":"2026-03-13T04:13:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-13T02:30:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-10T06:45:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-04T08:38:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-04T08:33:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2026-02-28T19:59:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95e1400d-375d-41cc-b9ff-dadada59b5b0","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T20:38:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 16:43:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8997704","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8997704","identity":"rs-8997704","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}