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

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

All You Ever Wanted To Know About Piles

What Are Piles?

Piles or haemorrhoids are swellings around the anus caused by enlarged or engorged veins.
Piles 01

Piles Symptoms

Piles may present as a lump at the anus or the lump may come out only when passing motion. Piles may also cause bleeding, typically dripping into the toilet bowl after opening the bowels. If the piles prolapse out and the blood inside clots, the piles become very painful. Patients may have difficulty sitting down. Not all of the above symptoms are caused by piles. I have personally seen many cases where the cause of the lump or bleeding is something else. Common examples include:

  • anal fissures
  • anal polyps
  • mucosal prolapse
  • perianal fistula
  • cancer
What Causes Piles?

Piles are most commonly caused by constipation. When your stools are hard, you have to strain hard during bowel movement. This increases the pressure inside your abdomen and also in the veins. Over time, your veins become swollen and engorged. Sometimes, when the veins get very large, they may prolapse or slip out through the anus. Chronic laxative abuse can also cause excessive straining. Pregnancy causes piles too. As your baby presses on your pelvic veins, this partially obstructs the flow of blood back to your heart and results in rising pressure in your pelvic veins, including the veins around the anus. Piles can also be caused by liver disease like cirrhosis, tumours in the pelvis and abnormal vessels around the anus.

Types of Piles

There are two types of piles: external and internal piles. External piles appear as a bluish lump at the anus. If a clot forms inside, it can become sensitive & painful. Internal piles are usually not visible. They often cause bleeding especially when opening bowels. If they get very large, they can prolapse or slip out as a lump at the anus. When this happens, the piles can become very painful. Often there is a combination of internal and external piles.

Treatment for Piles

If you have been told you have piles, do not delay in seeing a doctor. If you come to me for a check-up, I will conduct a detailed examination to make sure it is really piles and not something else. You’d also be advised in terms of treatment. You can then decide exactly how far you want to go and which treatment to opt for.

4 Common Ways To Treat Piles

If your piles are small and do not cause much trouble, they can be left alone. Small piles which bleed can be helped with medication. This includes medication to deal with constipation if you suffer from constipation. In terms of larger piles, they can be “banded” which means placing a small tight rubber band at the base of the pile. This stops blood flow into the pile so that the pile can shrink down. Later, the rubber band will fall off on its own. Another way to treat piles is by injection. This method has become less and less popular because it causes bleeding and discomfort. If you have very large or multiple piles, I suggest you remove them using surgery.

Using Surgery To Treat Piles

Many people are now opting for stapled haemorrhoidectomy (PPH haemorrhoidectomy) as a treatment method. In this treatment, we use a circular stapler to excise and staple the piles. As the operation is carried out on the inside, you won’t see any visible scars. There is considerably less pain using this method and healing is also faster compared to conventional surgery. However, not everyone can be treated this way. If your piles are not suitable for this method, you can still have them removed using conventional surgery, that is, removing the piles and then suturing the wound. You then have to wash twice daily with salt baths until the wounds heal, which takes about 3 to 4 weeks. Alternatives to stapling include ultrasound guided suture ligation of the piles as well as laser haemorrhoidectomy. Each method has its strengths and weaknesses.