The need to develop a classification system for giant goitres

Dear Editor,

With the widespread use of iodized salt, there has been a gradual reduction in the prevalence of endemic goiters. However, many patients with goiters in developing countries still present late for thyroidectomy, and a proportion will have giant goiters.¹ In the absence of a classification system, the clinical description of giant goiters has been subjective, thereby hindering the comparison of treatment outcomes.

Surgical resection of giant goiters is challenging, as it may be associated with increased perioperative risks, especially in many developing countries where goiters are still endemic.^2,3 These increased risks of morbidity and mortality in the surgical treatment of giant goiters highlight the need for a uniform classification system, as it would facilitate easier comparisons of outcomes and improve communication between clinicians involved in the management of giant goiters. Furthermore, proper perioperative planning and risk stratification in patients with giant goiters should be enhanced.

The proposed classification of giant goiters is based on tracheal involvement, displacement of the carotid sheath, and retrosternal extension using the computerized tomographic scan of the neck. Type 1 should be giant goiter with no trachea displacement/stenosis, nor carotid displacement; Type 2A is GG with deviated trachea no trachea compression and/or stenosis, or weakened trachea cartilage; Type 2B is GG with trachea compression and/or stenosis no weakened trachea cartilage; Type 2C has deviated trachea or trachea compression and/or stenosis with weakened trachea cartilage; Type 2D has carotid sheath displacement; Type 3 GG has a sub-sternal extension. However, this classification might also be performed using neck ultrasound and cervical X-rays in resource-poor settings. Tracheal compression and/or stenosis could be predictors of difficult intubation. Hence, such patients with severe tracheal stenosis may be operated on with local or regional anesthesia. In addition, weakened tracheal cartilage could predispose a patient with giant goiters to laryngomalacia with a need for tracheostomy after surgery. The displacement of the carotid sheath could predispose a patient with giant goiters to vascular injury during thyroidectomy. Furthermore, such patients could be at risk of brain ischemia and infarction.⁴

To validate or refine this proposed classification system, a Delphi study involving surgeons, endocrinologists, radiologists, and public health physicians is needed. These experts could help refine the proposed classification. This collaborative validation by experts could allow the deduction of a classification system, thereby promoting the development of guidelines for the treatment of giant goiters. This is critical for advancing the care of giant goiters in low-resource settings, where the prevalence of giant goiters is high.