The Flying Goitre

I first met Mr Syed Maktum in 2004. A good looking tall man of 42 with great poise, he came bearing a letter from his doctor about a thyroid swelling. He wore a worried look on his face.

Further tests revealed a 4.4cm solitary nodule in the right lobe of his thyroid gland. A needle biopsy of the nodule was reported to be benign (harmless).

Nevertheless, in view of the size, I recommended removal of the right lobe of the thyroid gland with the nodule.

He replied that he would think it over. He had a busy job as a senior airline steward and spent more time out of the country than in.

No show…

He reappeared in my clinic 2 years later in 2006 bearing another letter from a different doctor. The neck swelling had increased significantly in size and had started to push his trachea (windpipe) to the other side. By this time, there were many nodules, suggestive of multinodular goiter, a benign condition.

Multinodular goiters can get very big.

My personal record was a 900g monster, a subject of a future story. The need for surgery was clear.

However, thyroid surgery is not without risks. The main risk is to the recurrent laryngeal nerve, a nerve that lies very close to the thyroid gland.

Anyone taking on thyroid surgery would have to approach the area of the nerve with extreme caution, with extra careful and gentle dissection. Injury to the nerve would result in a weak or hoarse voice for the patient.

I carefully explained all this to him and after a good deal of persuasion, he agreed to go ahead and arrangements were made.

He never showed up.

“…my job depends on my voice…”

Fast forward to 2009.

He turns up again with another letter from yet another doctor.

By now, the thyroid gland had grown huge.

The previous nodule had grown from 4.4cm to a whopping 8.5cm. He had neck discomfort and his voice had gone hoarse by itself! Concerns had been raised at work about his neck swelling and his voice.

He was having difficulty doing up his collar. He was worried about his goiter, worried about his voice before surgery, and after surgery. He needed to make clear inflight announcements. His job and livelihood depended on it.

I had an ENT colleague look at him.

He diagnosed an infection of the vocal cords and thankfully his voice improved after a course of antibiotics. But it could have been due to the thyroid gland pressing on the nerve!

This time he did not need so much convincing. He revealed that his sister Puan A had been operated by me way back in 1998 for a thyroid swelling too. The operation had gone well, without complication and she was egging him to get on with it and have the operation done. He was very worried about the risk to his recurrent laryngeal nerve and the impact that would have on his job.

I did my best to reassure him, silently making a note to set aside plenty of time for his operation so I could approach the nerve with extra meticulous care. We looked at his flight schedules and made plans.

The operation proceeded without a hitch, staying well clear of the nerve. The left lobe looked normal so I left it well alone.

The lab report on the lump showed it to be benign. But best of all, his voice was completely normal afterwards and he was so relieved!

Another thyroid swelling!

In October this year, another sister of his, Puan K comes to my clinic (this time in Gleneagles Penang), also with a large thyroid swelling!

She had noticed it since last December but had put off coming to see me. This time, it was Syed Maktum who was egging her to come for a consult.

Her operation went smoothly. As she had hardly any normal thyroid tissue, I had to remove the entire gland. This carried an additional risk of a low blood calcium level after operation but happily, not only was her calcium completely normal afterwards but so was her voice.

Syed Maktum still flies and still has a hectic work schedule.

A model jumbo jet sits on my desk silently reminding me of Syed Maktum jetting his way around the world.

Syed Maktum & me, when he came to visit his sister at Gleneagles Penang
Syed Maktum & me, when he came to visit his sister at Gleneagles Penang
Postscript

My name is Syed Maktum. I had a thyroid operation on my neck done by Dr Khoo Saye Thiam. The operation was very successful and I am very happy because the growth in my neck was very big.

I am very impressed Dr Khoo did the operation very well and there no scar seen in my neck. My 2 sisters also had their thyroid operations done by Dr Khoo very successfully. Thank you for everything and all the best to Dr Khoo!

Syed Maktum, November 2013

Thyroid Gland Problems

Thyroid-02

Thyroid Gland Problems

The thyroid gland sits in the front of the neck, shaped like a butterfly, astride the windpipe (trachea). The thyroid’s job is to make thyroid hormone. This hormone controls the metabolic rate of every cell in our body, that is, it controls how fast we burn up energy.

 

Thyroid problems can be divided into 2 groups:

  1. Swellings of the thyroid gland (also known as goitre).
  2. Problems with the hormone level – either too much or too little.

Sometimes, you can get a mixture of both types of problems – example, an enlarged gland with too much hormone.

 

Symptoms of thyroid problems can also be divided into 2 groups
  1. Symptoms due to swelling of the thyroid gland and the pressure effects of those swellings.
  2. Symptoms due to thyroid hormone imbalance.

 

Swelling In The Neck – Goitre

Patients often come to see me with swellings in the neck.

Thyroid swellings are situated in the front of the neck and move when you swallow. Look at yourself in the mirror, then swallow. If you have a lump and it moves on swallowing, it may be that your thyroid gland is enlarged.

Common causes of thyroid swellings include:

  • Thyroid cysts
  • Multinodular goiter
  • Graves disease
  • Colloid nodules
  • Thyroid adenomas
  • Thyroid cancer

Sometimes, you may also have difficulty breathing or discomfort in the neck when swallowing. This could be due to the enlarged thyroid gland pressing on the windpipe (trachea) or gullet (oesophagus).

 

Too Much Hormone – Hyperthyroidism

You can also have symptoms of too much or too little hormone.

Common symptoms of too much hormone (hyperthyroidism):

  • Sensation of heart beating too fast (palpitations)
  • Shortness of breath
  • Weight loss (despite good appetite)
  • Anxiety and nervousness
  • Lack of energy
  • Tremor in the hands
  • Irregular periods
  • Both eyes protruding out (exophthalmos)

 

Too Little Hormone – Hypothyroidism

Common symptoms of too little hormone (hypothyroidism):

  • Lack of energy
  • Slow heart rate
  • Irregular periods or infertility
  • Increase in weight
  • Sleepiness
  • Dry skin
  • Constipation
  • Inability to tolerate cold

 

If you believe the above symptoms mirror what you suffer from and you suspect you have thyroid disease, make an appointment to see me.

I will usually arrange 2 tests: a simple blood test to check the hormone level and an ultrasound scan of the neck.

Occasionally we may have to proceed to a CT (Computer Tomography) scan of the neck and other tests. Once these tests and scans are done I will be able to advise you about your thyroid gland.

 

Treatment For Thyroid Problems

Treatment depends on the nature of your thyroid illness.

If you have a thyroid swelling, you may need surgery to remove it. Not all swellings require surgery so do not worry!

Most thyroid swellings are benign (not cancerous). However some thyroid swellings do turn out to be cancer. This is very important because most types of thyroid cancer are treatable and some have a very good prognosis.

If you think you have a thyroid swelling, you should see a doctor urgently. We may need to remove the thyroid swelling if there is a risk of the swelling being cancerous.

Some thyroid swellings need to be removed even if they are benign because they are pressing on some vital structure (like the windpipe / trachea or gullet / oesophagus) causing difficulty breathing or swallowing. If your thyroid gland is causing severe narrowing of the windpipe, you may be at risk of suffocation.

If you are worried about the swelling in your neck, come to see me and we will arrange a scan and some blood tests. ?I can better advise you once I have more information about the swelling in your neck.

If you have too much hormone, you may need medication to bring down the hormone levels.

If, on the other hand you have too little hormone, we need to do the exact opposite – you need to take hormone tablets to replace the missing hormone.

 

Tips For Thyroid Hormone Imbalance

If you have problems with your thyroid hormone levels (too much or too little), here’s what you can do.

  1. Take your medicines regularly without missing doses. If you do not take them properly, it can be difficult for your doctor to adjust your medicines so that your hormone levels are just right. For example, if you missed a week of medicines and your hormone levels are still high, I won’t know if I gave you too low a dose or if it was because you missed your medicines.
  2. Choose and then stick with the same doctor (it doesn’t matter if it’s me or not). I’ve known of patients who consult with many doctors and take medicines from all of them. They then mix up all the medicines from doctors A, B & C. Even though the medicines look different, they may actually be the same drug made by different companies, example one pink, another white etc.
  3. When you choose a doctor, pick one who is going to check and monitor your thyroid levels carefully with regular blood tests. Careful monitoring is just as important as taking medication regularly. When seeing a new patient with too much thyroid hormone, I usually monitor patients once a month at the start. When the levels become normal, I adjust the dose and lengthen the periods between check-ups to maybe 3 to 6 months.
  4. Be aware of the potential side effects of medication. Your doctor should be able to advise you what to look out for.
  5. If surgery is planned and you have too much thyroid hormone, it is important to bring the hormone levels down to normal before surgery to avoid getting a complication known as thyroid storm. This is a rare but potentially serious condition caused when a large amount of thyroid hormone is suddenly released into the circulation.

 

Treating Thyroid Problems Without Medication

Many patients ask me if they can treat thyroid problems without medication.

If your thyroid hormone levels are too low, the answer is no.

If your thyroid hormone levels are too high, there are 2 alternatives – surgery to remove the gland, and radioactive iodine treatment. Come to see me for further advice on this. In any case, treatment always begins with medicines first.

 

Hyperthyroidism & Pregnancy

I have hyperthyroidism (too much hormone). Can I get pregnant and should I stop my thyroid medicines during pregnancy?

Yes, you most certainly can get pregnant. However, if your hormones are very high, it may be a little more difficult to get pregnant.

If you are already pregnant you most certainly should continue your medication. Without your antithyroid medication, your hormones will become uncontrolled during pregnancy. That will make you ill.

Remember, if the mother is unwell, the baby will suffer too!

I advise women with hyperthyroidism during pregnancy to be especially careful about controlling their thyroid levels during pregnancy – maybe more frequent checks etc.

You should also inform your Obstetrician – it is possible the hyperthyroidism could affect the baby (not the medicines). I usually try to give patients the lowest dose possible during pregnancy.

 

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