Print ISSN: 2321-6379

Online ISSN: 2395-1893 Original Article

DOI:10.17354/SUR/2018/162

Comparative Study of Total Thyroidectomy and

Subtotal Thyroidectomy Regarding the Surgical
Management of Multinodular Goiter

D Nagender Rao1, G Siva Kumar2*

1
Assistant Professor, Department of Surgery, Gandhi Medical College, Secunderabad, Telangana, India,
2
Assistant Professor, Department of Surgery, Gandhi Medical College, Secunderabad, Telangana, India

Abstract
Background : Multinodular goitre refers to a generalised enlarged thyroid gland with recognisable nodules within it. The most
frequent cause of multinodular goitre is iodine deficiency. Medical care or radioactive iodine may be used for larger goitres; but
the best choice of MNG treatment is surgery, especially in cosmetic problem, compressive symptom, toxicity and suspicion of
malignancy. There are several methods for thyroid gland operation such as Subtotal Thyroidectomy (STT), Near-Total Thyroidectomy
(NTT), Hemi-thyroidectomy plus Subtotal resection (Dunhill procedure) and Total Thyroidectomy (TT). But the surgical method
of benign thyroid disease treatment is still controversial.
Objective : The primary objective of this study was to assess the effects of total or near-total thyroidectomy compared to subtotal
thyroidectomy for multinodular non-toxic goitre.
Materials and Methods : The study included fifty seven patients admitted at Gandhi Hospital referred with a prior diagnosis of
TMNG. 28 patients had undergone Subtotal Thyroidectomy where as 29 patients had undergone Total Thyroidectomy. Results
were interpreted based on the Thyroid profile, serum Calcium values; Incidence of post-operative complications and recurrence
of goitre.
Results : The results showed that among the patients who had undergone total thyroidectomy only two patients had developed
the complications of recurrent laryngeal nerve injury, superior laryngeal nerve injury, hypothyroidism and hypoparathyroidism,
whereas among the patients who underwent subtotal thyroidectomy none of these complications were seen; 5 patients out of 28
who had undergone subtotal thyroidectomy had developed recurrence at the end of 1 year, whereas there was no evidence of
recurrence among the patients who had undergone total thyroidectomy and the difference was found to be statistically significant.
Cocnclusions : It has been concluded that despite of the higher rate of post-operative complications, total thyroidectomy will be
more effective and beneficial in the surgical treatment of Multinodular Goitre.
Key words: Multinodular goiter, Subtotal thyroidectomy, Surgical management of multinodular goiter, Total thyroidectomy

INTRODUCTION toxic, the latter is called toxic MNG and associated with
hyperthyroidism; non-toxic goiter means that the nodules

A goiter is a swelling in the neck resulting from an

enlarged thyroid gland. Multinodular goiter (MNG)
consists of multiple nodules, can likewise be inactive or
Access this article online
Month of Submission : 08-2018
Month of Peer Review : 09-2018
Month of Acceptance : 10-2018
Month of Publishing : 10-2018
www.surgeryijss.com
do not secret thyroid hormones in an uncontrolled way. The
term MNG describes an enlarged, diffusely heterogeneous
thyroid gland. Initial findings may include diffuse
enlargement, but asymmetrical nodularity of the mass often
develops. MNG refers to a generalized enlarged thyroid
gland with recognizable nodules within it. Patients affected
by this condition often present with a non-symmetrical
enlargement of the thyroid gland with a visible swelling
in the anterior aspect of the neck and a heterogeneously
rough surface on palpation. One or more nodules can be
recognized. The most frequent cause of MNG is iodine

Corresponding Author: Dr. G Siva Kumar, Assistant Professor Department of Surgery, Gandhi Medical College, Secunderabad,
Telangana, India. E-mail:gsivakumar364@gmail.com

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 Rao and Kumar: Total vs subtotal thyroidectomy - surgical management of multinodular goitre
deficiency. Nodular goiters contain multiple foci and strands
of fibrous tissue, which result from scarring of multiple
hemorrhagic necroses occurring during goiter growth.
Therefore, the slowly growing number of newly formed
follicles has to squeeze into the meshes of an inelastic
network of connective tissue. Nodular growth pattern is the
inevitable consequence. Some particular nodules expand
because of excessive accumulation of colloid. It has been
concluded that most thyroid nodules in long-standing
goiters consist of ordinary, polyclonal goiter follicles which
expand in nodular fashion because they replicate within a
mold made out of a poorly extensible network of connective
tissue. Thyroid cancer is identified in 13.7% of the patients
operated for MNG. These nodules grow up at varying
rates and secrete thyroid hormone autonomously, thereby
suppressing thyroid-stimulating hormone-dependent
growth and function in the rest of gland. Medical care
or radioactive iodine may be used for larger goiters, but
the best choice of MNG treatment is surgery, especially
in cosmetic problem, compressive symptom, toxicity, and
suspicion of malignancy. There are several methods for
thyroid gland operation such as subtotal thyroidectomy
(TT) (STT), near-TT (NTT), hemithyroidectomy plus
subtotal resection (Dunhill procedure), and TT. TT is an
operation that involves the surgical removal of the whole
thyroid gland, with the preservation of the parathyroid
glands.[1] A small transverse incision is performed in the
inferior portion of the neck at the level of one of the natural
creases, 2–3 cm above the sternal notch. The platysma
is divided and the skin flaps are elevated superiorly and
inferiorly. The midline is divided on avascular plane and
the strap muscles are retracted laterally and the thyroid
is retracted medially. Using blunt dissection, the thyroid
is dissected from the surrounding structures, and then,
a ligation of the inferior and superior pole vessels is
performed. The inferior laryngeal nerve is visualized and
preserved as well as parathyroids. Finally, it is possible to
perform the lobectomy. The same technique is used for
both lobes. After TT, patients usually take a prescribed
oral synthetic thyroid hormone to prevent hypothyroidism.
NTT is an operation that involves the surgical removal
of both lobes except for a small amount of thyroid tissue
(i.e., <1.0 mL) on one or both sides in the vicinity of
the recurrent laryngeal nerve (RLN) entry point and the
superior parathyroid gland. This operation follows the same
technique as TT.[2-4] STT, including thyroid lobectomy and
isthmusectomy, is defined as a lobectomy with contralateral
subtotal resection leaving 3–5 g of normal remnant tissue
on the less affected side following the same technique as
described above. Thyroid hormonal release is maintained.
The Dunhill procedure consists of unilateral extracapsular
TT and contralateral subtotal thyroid lobe resection leaving
a thyroid stump of approximately 2 g of normal remnant
tissue. The most frequent complications of TT and STT are
transient or permanent hypocalcemia and recurrent nerve
palsy.[5,6] Hypocalcemia is caused by the unintentional
2 IJSS Journal of Surgery  |  Sep-Oct 2018 | Volume 4 | Issue 5
excision of the parathyroid glands or by devascularization of
the parathyroid glands during the surgical maneuvers. Rates
of postprocedural hypocalcemia are approximately 5%,
resolving in 80% of cases within approximately 12 months.
Transient or permanent recurrent nerve palsy occurs due
to a traumatized inferior laryngeal nerve. A wide spectrum
of injuries to the voice, swallowing mechanisms, or both
can occur because of the mixed fibers contained within
the nerve. A temporary or permanent voice change can
result, which can be extremely distressing to the patient.
Recurrent nerve palsy, when unilateral, presents with a
one-sided paralyzed vocal cord causing voice change.[7-11]
Bilateral nerve palsy can seriously jeopardize the breathing
mechanism and often requires the establishment of surgical
airways. Other disadvantages of STT for treating MNG are
that the procedure does not reduce the risk of persisting
symptoms and has a high recurrence rate (30–50%) due
to gland remnants. The aim of a surgeon performing STT
and NTT for MNG is to try to keep the patient euthyroid
postoperatively avoiding the need for lifelong thyroid
replacement.[12] However, despite the little remnant
thyroid tissue in all surgical procedures, except of total
thyroidectomy, the necessity of treatment with thyroid
hormone still remains. In this context, this present study was
designed to compare and assess the clinical profile and the
outcomes of two types of surgical interventions for goiter.
The primary objective was to assess the effects of total or
NTT compared to STT for multinodular non-toxic goiter.
PATIENTS AND METHODS
• Study design: This is a prospective cross-sectional
study.
• Approval: This study received approval from the
college ethical committee.
• Setting: Gandhi Medical Hospital, Hyderabad.
• Participants: 57 patients admitted to Gandhi Medical
Hospital.
• Study period: June 2016–October 2017.
Inclusion Criteria
The following criteria were included in the study:
1. Age group >18 years.
2. All patients with final pathologic diagnosis consistent
with MNG.
3. Patients who gave consent for surgery.
Exclusion Criteria
The following criteria were excluded from the study:
1. Age group <18 years.
2. Previously known thyroid malignancy.
3. Final pathologic process containing thyroid
neoplasm requiring complete thyroidectomy.
4. Patient not giving consent for surgery.
 Rao and Kumar: Total vs subtotal thyroidectomy - surgical management of multinodular goitre

OBSERVATIONS AND RESULTS
All patients were referred with a prior diagnosis of toxic
multinodular goiter determined by clinical presentation,
laboratory testing, and radiographic imaging (including
ultrasound [US] and isotopic scanning). Pre-operative
evaluation involved thyroid blood test, US, and fiberoptic
laryngoscopy. If US showed nodules with a diameter
>10 mm or suspicious features (calcification and irregular
contours), the patient underwent fine-needle aspiration
cytology of the thyroid gland during the procedure.
Patients were also evaluated with a questionnaire assessing
hyperthyroid symptoms such as weight loss, thermophobia,
hand trembling, tachycardia (heart rate >100 beats per
minute), diarrhea, and insomnia. Preoperatively, all patients
were made euthyroid by the use of antithyroid drugs, and
Lugol solution (equimolar potassium iodine and metallic
iodine) was added for the past 8 days before surgery to
decrease thyroid blood flow. Intraoperatively, an attempt
was made to preserve all the parathyroid glands in situ but,
if resected, they were transplanted and fragmented into a
pouch of the sternocleidomastoid muscle. The recurrent
nerves were systematically identified using the technique
from the upper mediastinum to the cricothyroid muscle. All
patients were drained using a vacuum 8 gauge polyvinyl
chloride. Immediate post-operative evaluation involved the
serum level of parathyroid hormone (PTH), serum calcium,
and inorganic phosphorus on day 0 (4–6 h after the
procedure) and day 2 (evaluation was repeated if values
Table 1: Frequency distribution of the study participants in
relation to certain variables
Variables Frequency (%)
Age group (year)
41–45
46–50
51–55
56–60
Gender
Male
Female
Family history of goiter
Positive
Negative 51 (89.5)
Size of the goiter
Mean vertical diameter 6.8 (1.58)
Mean horizontal diameter 6.4 (1.01)
Border of the goiter
Well defined
Diffuse
Position of Trachea
Midline
Shift to rig
Type of surgery
STT
TT
STT: Subtotal thyroidectomy, TT: Total thyroidectomy
were outside the normal range). Fiber-optic laryngoscopy
was undertaken by an ear, nose, and throat specialist
1 week after surgery to evaluate laryngeal function. We
recorded the following complications: Bleeding requiring
repeat surgery, paresia or palsy of the vocal cords,
hypoparathyroidism, wound infection, and other systemic
complications. Hypoparathyroidism was defined as the
need for calcium supplementation to reach the normal
level of calcium in serum (2.2 mmol/L) and a low serum
level of PTH (<15 pg/mL). Blood samples for PTH testing
were taken 4–8 h after the procedure and repeated at 48
h and 1 week. The length of hypoparathyroidism was
arbitrarily divided into four periods: >1 week, >1 month,
6–12 months, and permanent. Patients were reevaluated
at 1 week, 1 month, 2 months, 6 months, 12 months,
and once a year after surgery. This follow-up involved
physical examination, thyroid blood test, and serum PTH
(if necessary). In this study, it is depicted that almost 49%
of the people had undergone STT and the remaining
51% had undergone TT. The types of surgery for the
patients were decided based on their willingness and
consent. Table 1 shows the frequency distribution of study
participants in relation to certain variables significant in
the study. Table 2 shows the mean and standard deviation
(SD) of the thyroid profile parameters and the serum
calcium levels among the patients who underwent STT.
It is inferred from the table that the mean levels of all the
thyroid parameters and the serum calcium levels were
all in the range of the normal values. Similarly, the mean
and SD of the thyroid profile parameters and the serum
calcium levels among the patients who underwent TT
were also within normal limits. The comparison of thyroid
profile parameters and the serum calcium levels among the
patients who underwent subtotal and TT in Table 2 showed
5 (9) Table 2: Comparison of the mean of thyroid profile and
17 (30) serum calcium levels among the patients who underwent
29 (50) STT and TT
6 (11)
Thyroid profile and serum calcium Mean values
15 (26) STT TT
42 (74) Free T3 (ng/dL) 5.73 5.16
Free T4 (ng/dL) 10.97 10.43
6 (10.5) TSH (ng/dL) 4.38 5.09
Serum calcium (mg/dL) 9.46 9.10
STT: Subtotal thyroidectomy, TT: Total thyroidectomy, TSH: Thyroid-stimulating hormone
12 (21)
Table 3: Post-operative complications among the patients
45 (79) who underwent STT
Post-operative complications STT TT
49 (87) RLN injury 0 2/29 (7)
8 (13) Superior laryngeal nerve injury 0 2/29 (7)
Hypothyroidism 0 2/29 (7)
28 (49) Hypoparathyroidism 0 2/29 (7)
29 (51) STT: Subtotal thyroidectomy, TT: Total thyroidectomy, RLN: Recurrent laryngeal nerve

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 Rao and Kumar: Total vs subtotal thyroidectomy - surgical management of multinodular goitre
Table 4: Incidence of recurrence of goiter among the study
population at the end of 1 year
Recurrence of goiter STT TT
Present 5 0
Absent 23 29
Total 28 29
STT: Subtotal thyroidectomy, TT: Total thyroidectomy
that except the free T3 levels all the other serological
parameters were almost similar in both the groups with
no significant difference between them. The mean free T3
level was found to be slightly lower in the TT group, as
one patient had developed hypothyroidism in that group.
Table 3 shows the post-operative complications among
the patients who underwent subtotal and TT. It is inferred
from the table that among the patients who had undergone
total thyroidectomy only two patients had developed
the complications of RLN injury, superior laryngeal
nerve injury, hypothyroidism, and hypoparathyroidism,
whereas among the patients who underwent STT none of
these complications were seen. These were the common
complications occurred in TT based on the literature
review. Table 4 shows the incidence of recurrence of goiter
among the study population at the end of 1 year. It is
depicted from the table that five patients of 28 who had
undergone STT had developed recurrence at the end of
1 year, whereas there was no evidence of recurrence among
the patients who had undergone total thyroidectomy and
this difference was found to be statistically significant.
DISCUSSION
MNG is characterized by progressive thyroid growth. It
can, due to its anatomical location, expand to jeopardize
neighboring structures and lead to different compression
symptoms. Most common are tracheal and esophageal
compression. The surgical treatment of benign thyroid
disease is still controversial, although many surgical
subspecialties have developed, each has many angles and
views. Many treatment modalities have been advocated
for the surgical management of MNG, that is, TT, NTT,
STT, and hemithyroidectomy; nevertheless, clarity is
missing regarding the safest and best option for the
patients on a longer perspective. The indications for
TT in the management of thyroid diseases are not well
defined. The literature lists a few, such as histories of
head and neck irradiation, an MNG grossly involving
both the lobes, compressive symptoms, and nodule
with suspected malignancy. If the goiter is voluminous
with compressive symptoms or if it is not possible to
leave a grossly homogeneous thyroid remnant tissue
because of the location of possible nodules, TT is
recommended.[13-15] There is a growing evidence that
TT is appropriate for patients with MNG where there is
a significant nodular disease involving both the lobes.
4 IJSS Journal of Surgery  |  Sep-Oct 2018 | Volume 4 | Issue 5
STT may be the best elective procedure in older patients
to avoid total and permanent dependence on drugs.
Some authors favor the subtotal procedure because of its
lower incidence of iatrogenic injuries such as RLN palsy
and hypoparathyroidism. The goal of surgical treatment
in MNG should be to eliminate the disease with a low
complication rate and to minimize the necessity for
reoperation because the risk of permanent complications
has been found to be higher in reoperations for recurrent
disease than in primary operations with extensive disease.
[16]
If a surgeon leaves abnormal thyroid tissue in a patient
with MNG, subsequent reoperation might be required.
Recurrence develops in as many as 17.8% of cases after
subtotal resection despite the prophylaxis; without
suppressive therapy, the rate of recurrence increases to
47%. MNG is clinically important for several reasons. It
may cause thyroid dysfunction or compressive symptoms,
but it is even more important because of the need to
exclude thyroid cancer.[17] The reported prevalence of
malignancy in thyroid nodules, evaluated by biopsy,
ranges from 4% to 6.5% and is largely independent of
the nodule size. Complications of thyroid surgery consist
of temporary or permanent RLN palsy, temporary and
permanent hypocalcemia, hematoma, and seroma.
CONCLUSIONS
In TT, there is an expanded hazard of iatrogenic
wounds. Yet, when the recurrence of complexities in
intermittent activities and the malignancy possibility of
the thyroid tissue left behind are mulled over, we trust
that notwithstanding the higher rate of post-surgery
complications TT will be more valuable in the careful
treatment of benign thyroid diseases, particularly those
which are respective to substernal space or which gave
compression side effects.
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How to cite this article: Rao DN, Kumar GS. Comparative Study
of Total Thyroidectomy and Subtotal Thyroidectomy Regarding the
Surgical Management of Multinodular Goiter. IJSS Journal of Surgery
2018;4(5):1-5.
Source of Support: Nil, Conflict of Interest: None declared.
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