Two Large Symptomatic Thyroid Cysts in Multinodular Goiters Treated with Ultrasound-Guided Ethanol Sclerotherapy

Case Report

J Dis Markers. 2014;1(2): 1007.

Two Large Symptomatic Thyroid Cysts in Multinodular Goiters Treated with Ultrasound-Guided Ethanol Sclerotherapy

Milan Halenka*, David Karasek and Zdenek Frysak

Department of Internal Medicine, Palacky University, Czech Republic

*Corresponding author: Milan Halenka, 3rd Department of Internal Medicine, Faculty of Medicine and Dentistry, Palacky University, 775 20 Olomouc, Czech Republic

Received: August 04, 2014; Accepted: Aug 20, 2014; Published: Aug 25, 2014


Ultrasound-guided ethanol sclerotherapy is used as an alternative to surgery in the treatment of thyroid cysts. The method is effective, repeatable, and cheap and can be performed in an outpatient setting. The risks are related to ethanol leaking into the surrounding tissues but serious complications are only seen in a small proportion of procedures. The approach is successfully used to treat small- and medium-sized cysts of less than 50 ml of volume. It may also be attempted in large, mostly complex cysts causing significant mechanical problems. These are two reports documenting cases of successfully treated large symptomatic cysts (80 and 170 ml) in multinodular goiters in elderly patients with co morbidities who either refused a surgical approach or in whom surgery was ruled out.

Keywords: Ultrasound-guided ethanol sclerotherapy; Large symptomatic cysts thyroid cysts


A multinodular goiter is a common condition, especially in elderly patients. The goiter is frequently visible, causing mechanical problems. The prevalence rates of thyroid nodules detected by palpation and by Ultrasound (U/S) are 4-7% and 19-67%, respectively [1]. Complex nodules develop due to hemorrhage or degenerative changes and are present in 18%-35% of surgical specimens [2]. In U/S examinations, complex nodules account for up to 50% of all palpable and non-palpable nodules [3].

Cysts with the fluid component making up more than 60% of their volume are called complex [4,5] in some individuals, large complex cysts with a volume of more than 50 ml may appear, causing significant mechanical and cosmetic difficulties that have to be solved. Naturally, the approach of choice is surgery. In most cases, simple evacuation fails to be successful, even in small cysts. The recurrence rates are 58%-80%, depending on the size, content and number of previous aspirations [6,7]. Large complex cysts recur quite commonly [8]. In patients unsuitable for surgery, an alternative approach is ethanol sclerotherapy which may produce a significant reduction in cyst volume of more than 50% or, sometimes, even disappearance of the fluid component. To assess the success of treatment, a Volume Reduction Rate (VRR) is calculated using the following formula: initial cyst volume - final cyst volume / initial cyst volume x 100 = result as a percentage. The mechanism of action of ethanol is related to coagulative necrosis, reactive fibrosis and small vessel thrombosis [7]. These large cysts already require repeated administration of ethanol, meaning a higher risk of its leakage into the surrounding tissue and more severe complications. Yet the method has already been used successfully [8-10].


Cytological examination showed that the aspirate was benign in all the cases. The patients gave informed consent to sclerotherapy. The examination and U/S ethanol sclerotherapy was performed using the iU 22, Philips, 10-MHz linear probe. During the procedure, the patient was in the supine position with the head slightly tilted back. A 20-gauge needle was used for evacuation of the cyst and subsequent sclerotherapy. The approach was non-aspiration of the instilled 96% ethanol [5,6,11]. First, nearly all cyst content was evacuated, with a small amount of the colloid being left for visualization of the needle tip. While the needle was kept in the cystic cavity, the evacuation syringe was replaced with a syringe with 96% ethanol which was slowly instilled into the collapsed cavity. U/S check-ups after latest sclerotherapy were planned 3, 6, and 12 months later. Laboratory findings (TSH, normal range 0, 35-4, 94 mIU/l) were checked before and after sclerotherapy.

Case report 1

A 79-year-old male with a 15-year history of a multinodular goiter developed a mass in the right thyroid lobe causing mechanical problems as he could not button his shirt (Figure 1). The underlying cause was a large complex cyst repeatedly (3 times) biopsied by a local radiologist, with benign cytology results. A U/S scan performed in our department revealed a large multinodular goiter with a volume of 130 ml and a large 80-ml complex cyst in the right lobe, with a predominant cystic component, smooth inner wall and no septa (Figure 2a). Given the patient's co morbidities, surgery was ruled out and ethanol sclerotherapy was proposed. Initially, 70 ml of brown fluid were evacuated. Cytological examination showed only degenerative but not benign changes. This was followed by sclerotization with 96% ethanol. Every three weeks, the cyst was evacuated and 5 ml of 96% ethanol were instilled into it. The procedure was carried out five times. Gradually, the cyst volume reduced to 35 ml, 22 ml, 20 ml, 16 ml and 14 ml. One month after completion of therapy, the solid residue of the cyst had a volume of 9 ml (Figure 2b). The complex cyst regressed from the initial volume of 80 ml to the final volume of 9 ml that is a VRR of 89%. A total of 25 ml of 96% ethanol was administered, which was equal to 31% of the initial cyst volume. The procedures were tolerated well by the patient who only reported mild local pain on two occasions after ethanol instillation that subsided within 24 or 48 hours. Patient was before and after sclerotherapy euthyroid, TSH 2.14 resp. 2.23 mIU/l.