Multinodular goitre is characterized by enlargement of the thyroid gland with multiple structurally and functionally heterogeneous nodules. It is particularly prevalent in regions where iodine deficiency remains an important public health concern. In India, iodine deficiency disorders have historically been reported from several regions, including parts of the Sub-Himalayan belt and Deccan Plateau. The development of multinodular goitre is multifactorial. Persistent or fluctuating thyroid-stimulating hormone stimulation, abnormalities in iodine metabolism, genetic susceptibility, and environmental influences may result in repeated cycles of follicular hyperplasia and involution. Over time, these changes can produce nodular transformation, fibrosis, cystic degeneration, and calcification. Multinodular goitre may occur in euthyroid, hypothyroid, or hyperthyroid states. Most patients develop multinodular goitre gradually and may remain asymptomatic for many years. However, progressive enlargement may eventually result in compression of the trachea, oesophagus, or recurrent laryngeal nerve, producing dyspnoea, dysphagia, or voice changes. An important component of evaluation is exclusion of malignancy. Thyroid function testing, ultrasonography, computed tomography in selected large or substernal goitres, and fine-needle aspiration cytology are important components of assessment. Giant multinodular goitre in an adolescent or young adult is relatively unusual. The present case is noteworthy because of the prolonged duration of disease, marked thyroid enlargement, young age, male sex, absence of significant compressive symptoms, and successful surgical management despite considerable anatomical distortion Case Presentation An 18-year-old male presented to the ENT outpatient department of Rani Durgavati Medical College, Banda, with a large anterior neck swelling. According to the history, the swelling had been present for approximately 10 years and had increased gradually in size. The principal concern of the patient was cosmetic deformity. The swelling had an insidious onset and was gradually progressive. There was no history of dysphagia or dyspnoea. The patient did not report symptoms suggestive of thyroid hormone excess such as palpitations or tremors. There was no significant past medical history, and the family history was non-contributory.On examination, there was a diffuse, large, non-tender thyroid enlargement. The swelling was not fixed to the overlying skin or underlying structures. No cervical lymphadenopathy was detected. The patient was clinically euthyroid. The clinical profile is summarized in Table 1. Investigations Thyroid function tests were within normal limits, consistent with a euthyroid state. Ultrasonography demonstrated significant enlargement of both thyroid lobes with multiple nodules and increased vascularity. Fine-needle aspiration cytology revealed moderately cellular smears composed of cohesive monolayered sheets of follicular epithelial cells with abundant colloid. The cytological impression was nodular colloid goitre, with no evidence of malignancy. Contrast-enhanced CT of the neck showed gross enlargement of both thyroid lobes extending from the hyoid region to the thoracic inlet. The right lobe measured approximately 21 × 12 × 10 cm, while the left lobe measured approximately 24.5 × 10 × 10.5 cm. The carotid arteries and internal jugular veins were displaced posterolaterally. There was no retrosternal or extracapsular extension and no radiological evidence suggestive of malignancy. Table 2. Investigations Summary Investigation Findings Thyroid function tests Within normal limits Ultrasonography Enlarged bilateral thyroid with multiple nodules and increased vascularity FNAC Nodular colloid goitre; benign cytology CECT neck Gross bilateral thyroid enlargement extending from hyoid to thoracic inlet Right thyroid lobe 21 × 12 × 10 cm Left thyroid lobe 24.5 × 10 × 10.5 cm Major vessels Carotid artery and IJV displaced posterolaterally Retrosternal extension Absent Suspicion of malignancy Absent Management Considering the enormous size of the thyroid gland and the associated cosmetic deformity, total thyroidectomy was planned. The procedure was performed under general anaesthesia. Intraoperatively, the thyroid gland was found to be grossly enlarged and multinodular, with considerable anatomical distortion. The strap muscles were adherent and required division followed by re-suturing. The sternocleidomastoid muscle was partially involved and was managed accordingly. Major vascular structures were displaced but could be preserved. Particular attention was given to identification and preservation of the recurrent laryngeal nerves. Both recurrent laryngeal nerves and superior laryngeal nerves were identified and preserved. An enlarged pyramidal lobe was also identified and excised. A Romovac suction drain was placed at the end of the procedure. Table 3. Intraoperative Findings and Management Parameter Findings Procedure Total thyroidectomy Anaesthesia General anaesthesia Thyroid gland Grossly enlarged and multinodular Anatomical distortion Present Strap muscles Adherent; divided and re-sutured Sternocleidomastoid muscle Partially involved; managed intraoperatively Major vessels Displaced but preserved Recurrent laryngeal nerves Identified and preserved bilaterally Superior laryngeal nerves Preserved Pyramidal lobe Enlarged and excised Drain Romovac suction drain Postoperative Course The patient was successfully extubated after surgery and maintained adequate oxygen saturation. On the first postoperative day, he developed a transient breathy voice. This was considered compatible with temporary recurrent laryngeal nerve neuropraxia. The patient was closely monitored. There was no respiratory compromise. The postoperative course was otherwise uneventful. The drain was removed on postoperative day 5. The patient's voice gradually returned to normal, with complete recovery and no evidence of permanent recurrent laryngeal nerve injury. The source material records transient hypocalcaemia in the overall case description and notes successful management with calcium and vitamin D supplementation during the postoperative period. Table 4. Postoperative Outcome Parameter Outcome Extubation Successful Oxygen saturation 95–96% Voice Transient breathy voice on day 1 Hypocalcaemia Transient/managed appropriately Drain removal Postoperative day 5 Overall recovery Uneventful Histopathology Benign nodular colloid goitre Histopathology Histopathological examination of the excised thyroid tissue demonstrated multinodular colloid goitre. There was no evidence of malignancy.

Multinodular goitre generally develops progressively and may remain asymptomatic for prolonged periods. Its management depends on thyroid function, gland size, symptoms, cosmetic concerns, and the possibility of malignancy. Medical treatment and radioactive iodine have roles in selected patients, particularly depending on thyroid functional status. However, surgery is an important definitive treatment for large goitres, especially when there is substantial enlargement, cosmetic deformity, compressive symptoms, or concern regarding malignancy. The present case is unusual because the patient was only 18 years old and had harboured the swelling for approximately 10 years. Despite the enormous size of the thyroid, he did not present with significant dysphagia or dyspnoea. Imaging demonstrated considerable displacement of the surrounding vascular structures, emphasizing the importance of detailed preoperative imaging and surgical planning. Total thyroidectomy in a giant goitre can be technically challenging because of distortion of normal anatomical landmarks and close proximity of the recurrent and superior laryngeal nerves to the enlarged thyroid gland. In the present case, careful identification and preservation of both recurrent laryngeal nerves and superior laryngeal nerves allowed the patient to recover without permanent vocal cord-related morbidity. The transient postoperative breathy voice resolved completely during follow-up, suggesting temporary neuropraxia rather than permanent nerve injury. The overall outcome was favourable, with successful removal of the giant multinodular thyroid and histopathological confirmation of a benign colloid lesion.

Giant multinodular goitre can occur in young patients and may remain clinically silent for several years despite massive enlargement. The present case emphasizes that the absence of compressive symptoms does not necessarily indicate limited disease. A systematic evaluation using thyroid function tests, ultrasonography, FNAC, and cross-sectional imaging is important for determining the nature and extent of the lesion and for planning surgery. In giant multinodular goitre, total thyroidectomy can provide definitive treatment, but the procedure requires careful surgical planning because of distorted anatomy and the proximity of important neurovascular structures. Early recognition and appropriate management can prevent future airway, swallowing, vascular, or neurological complications. This case demonstrates that even a giant multinodular goitre in a young male can be successfully managed with meticulous surgical technique and appropriate postoperative monitoring.

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