Overview Of Goiter

A goiter (GOI-tur) is an abnormal enlargement of your thyroid gland. Your thyroid is a butterfly-shaped gland located at the base of your neck just below your Adam’s apple. Although goiters are usually painless, a large goiter can cause a cough and make it difficult for you to swallow or breathe.

Goiter is a condition in which the thyroid gland grows larger. The thyroid gland is a small, butterfly-shaped gland located in the neck, below Adam’s apple. It secretes hormones that help regulate bodily functions, including metabolism, the process that turns food into energy. It also regulates heart rate, respiration, digestion, and mood.

The thyroid gland produces the hormones thyroxine (also called T4) and triiodothyronine (also called T3). (Most of the T4 is changed to T3 outside of the thyroid.) These hormones play a role in certain bodily functions, including body temperature, mood, and excitability, pulse rate, digestion, and others.

The most common cause of goiters worldwide is a lack of iodine in the diet. In the United States, where the use of iodized salt is common, a goiter is more often due to the over or underproduction of thyroid hormones or to nodules in the gland itself.

A condition that increases the size of your thyroid is called a goiter. A goiter may develop in anyone but is more common in women. Sometimes, it affects the way the thyroid functions.

Treatment depends on the size of the goiter, your symptoms, and the cause. Small goiters that aren’t noticeable and don’t cause problems usually don’t need treatment.

The thyroid is a butterfly-shaped gland situated in front of the windpipe. It is responsible for producing and secreting hormones that regulate growth and metabolism.

Most cases of goiter are categorized as “simple” goiters. These do not involve inflammation or any detriment to thyroid function, produce no symptoms, and often have no obvious cause.

Some people experience a small amount of swelling. Others can have considerable swelling that constricts the trachea and causes breathing problems.

An enlarged thyroid does not necessarily mean that the thyroid gland is working incorrectly. A person with goiter may have a thyroid gland that is:

• creating too much hormone, known as hyperthyroidism
• creating too little hormone, known as hypothyroidism
• creating the typical amount of hormone, known as euthyroidism

Goiters are more common in females than males, especially after menopause. Goiters and thyroid disease are generally more common after the age of 40.

What are the Symptoms of a Goiter?

The term “goiter” simply refers to the abnormal enlargement of the thyroid gland. It is important to know that the presence of a goiter does not necessarily mean that the thyroid gland is malfunctioning. A goiter can occur in a gland that is producing too much hormone (hyperthyroidism), too little hormone (hypothyroidism), or the correct amount of hormone (euthyroidism). A goiter indicates there is a condition present that is causing the thyroid to grow abnormally.

A goiter can present as a palpable or visible enlargement of the thyroid gland at the base of the neck. A goiter, if associated with hypothyroidism or hyperthyroidism, may be present with symptoms of the underlying disorder. For hyperthyroidism, the most common symptoms are associated with adrenergic stimulation: tachycardia (increased heart, palpitations, nervousness, tremor, increased blood pressure, and heat intolerance.

Clinical manifestations are often related to hypermetabolism, (increased metabolism), excessive thyroid hormone, an increase in oxygen consumption, metabolic changes in protein metabolism, immunologic stimulation of diffuse goiter, and ocular changes (exophthalmos). Hypothyroid people commonly have poor appetite, cold intolerance, constipation, lethargy, and may undergo weight gain. However, these symptoms are often non-specific and make diagnosis difficult.

The primary symptom of a goiter is noticeable swelling in your neck. If you have nodules on your thyroid, they may range in size from very small to very large. The presence of nodules may increase the appearance of swelling.

Not all goiters cause signs and symptoms. When signs and symptoms do occur they may include:

• A swelling at the base of your neck that may be particularly obvious when you shave or put on makeup
• A tight feeling in your throat
• Coughing
• Hoarseness
• Difficulty swallowing
• Difficulty breathing
• Hoarseness (scratchy voice)
• Neck vein swelling
• Dizziness when the arms are raised above the head

Other, less common symptoms include:

• Difficulty breathing (shortness of breath)
• Coughing
• Wheezing (due to squeezing of the windpipe)
• Difficulty swallowing (due to squeezing of the esophagus, or “food tube”)

Some people who have a goiter may also have hyperthyroidism or overactive thyroid. Symptoms of hyperthyroidism can include:

• An increased resting pulse rate
• Rapid heartbeat
• Diarrhea, nausea, vomiting
• Sweating without exercise or increased room temperature
• Shaking
• Agitation

Some people with goiter may also have hypothyroidism or underactive thyroid. Symptoms of hypothyroidism can include:

• Fatigue (feeling tired)
• Constipation
• Dry skin
• Weight gain
• Menstrual irregularities

Signs and tests of goiter:

• Measurement of thyroid-stimulating hormone (TSH) and free thyroxine (T4) in the blood
• The thyroid scan and uptake
• Ultrasound of thyroid — if nodules are present, a biopsy should be done to check for thyroid cancer

What are Causes goiter?

Worldwide, the most common cause for goiter is iodine deficiency, commonly seen in countries that scarcely use iodized salt. Selenium deficiency is also considered a contributing factor. In countries that use iodized salt, Hashimoto’s thyroiditis is the most common cause. Goiter can also result from cyanide poisoning; this is particularly common in tropical countries where people eat the cyanide rich cassava root as the staple food.

Thyroid nodules, masses in the thyroid gland, can be the result of benign cell overgrowth (adenomatous hyperplasia) or actual discrete tumors comprised of thyroid cells that can be benign or cancerous.  Thyroid nodules can sometimes contain fluid, which usually collects due to bleeding from the fragile blood vessels in thyroid tumors, so-called cystic degeneration.  This event sometimes causes the sudden onset of pain and swelling in the front of the neck, which typically subsides over several days. 

Fortunately, more than 90% of thyroid nodules are not cancers, but malignancy should be considered in every affected person.  Often patients with small thyroid nodules, less than 1 cm in diameter, and no risk factors for thyroid cancer can simply be reexamined or imaged by sonography to be sure the nodule is not enlarging.  For larger nodules, additional studies are usually indicated, as described below.

Your thyroid gland produces two main hormones thyroxine (T-4) and triiodothyronine (T-3). These hormones circulate in your bloodstream and help regulate your metabolism. They maintain the rate at which your body uses fats and carbohydrates, help control your body temperature, influence your heart rate, and help regulate the production of proteins.

Your thyroid gland also produces calcitonin a hormone that helps regulate the amount of calcium in your blood.

Your pituitary gland and hypothalamus control the rate at which T-4 and T-3 are produced and released.

The hypothalamus an area at the base of your brain that acts as a thermostat for your whole system signal your pituitary gland to make a hormone known as thyroid-stimulating hormone (TSH). Your pituitary gland also located at the base of your brain releases a certain amount of TSH, depending on how much thyroxine and T-3 are in your blood. Your thyroid gland, in turn, regulates its production of hormones based on the amount of TSH it receives from the pituitary gland.

Having a goiter doesn’t necessarily mean that your thyroid gland isn’t working normally. Even when it’s enlarged, your thyroid may produce normal amounts of hormones. It might also, however, produce too much or too little thyroxine and T-3.

Several things can cause your thyroid gland to enlarge. Some of the most common are:

Simple goiters develop when the thyroid gland does not make enough hormones to meet the body’s needs. The thyroid gland tries to make up for this shortage by growing larger.

Endemic goiters occur in people in certain parts of the world who do not get enough iodine in their diet (iodine is necessary to make thyroid hormone). For instance, a lack of iodine in the diet is still a common problem in parts of central Asia and central Africa. Because iodine is added to table salt in the United States and other countries, this type of goiter usually does not occur in these countries.

Sporadic goiters, in most cases, have no known cause. In some cases, certain drugs can cause this type of goiter. For example, the drug lithium, which is used to treat certain mental health conditions, as well as other medical conditions, can cause this type of goiter.

Iodine deficiency. Iodine is essential for the production of thyroid hormones and is found primarily in seawater and in the soil in coastal areas. In the developing world, people who live inland or at high elevations are often iodine deficient and can develop goiters when the thyroid enlarges in an effort to obtain more iodine. Iodine deficiency may be made worse by a diet high in hormone-inhibiting foods, such as cabbage, broccoli, and cauliflower.

In countries where iodine is routinely added to table salt and other foods, a lack of dietary iodine isn’t usually the cause of goiters.

Graves’ disease. A goiter can sometimes occur when your thyroid gland produces too much thyroid hormone (hyperthyroidism). In someone who has Graves’ disease, antibodies produced by the immune system mistakenly attack the thyroid gland, causing it to produce excess thyroxine. This overstimulation causes the thyroid to swell.

Hashimoto’s disease. A goiter can also result from an underactive thyroid (hypothyroidism). Like Graves’ disease, Hashimoto’s disease is an autoimmune disorder. But instead of causing your thyroid to produce too much hormone, Hashimoto’s damages your thyroid so that it produces too little.

Sensing a low hormone level, your pituitary gland produces more TSH to stimulate the thyroid, which then causes the gland to enlarge.

• Multinodular goiter. In this condition, several solid or fluid-filled lumps called nodules to develop in both sides of your thyroid, resulting in overall enlargement of the gland.
• Solitary thyroid nodules. In this case, a single nodule develops in one part of your thyroid gland. Most nodules are noncancerous (benign) and don’t lead to cancer.
• Thyroid cancer. Thyroid cancer is far less common than benign thyroid nodules. A biopsy of a thyroid nodule is very accurate in determining whether it’s cancerous.
• Pregnancy. A hormone produced during pregnancy, human chorionic gonadotropin (HCG), may cause your thyroid gland to enlarge slightly.
• Inflammation. Thyroiditis is an inflammatory condition that can cause pain and swell in the thyroid. It may also cause the body to produce too much or too little thyroxine.

Other causes of goiter include:

• The body’s immune system attacking the thyroid gland (autoimmune problem)
• Certain medicines (lithium, amiodarone)
• Infections (rare)
• Cigarette smoking
• Eating very large amounts of certain foods (soy, peanuts, or vegetables in the broccoli and cabbage family)
• Toxic nodular goiter, an enlarged thyroid gland that has a small growth or many growths called nodules, which produce too much thyroid hormone

Simple goiters are more common in:

• People over age 40
• People with a family history of goiter
• People who are born and raised in areas with iodine deficiency
• Women

Types of Goiters

A goiter may be classified either as nodular or diffuse. Nodular goiters are either of one nodule (unimodular) or of multiple nodules (multinodular).

Growth pattern

• Uninodulargoitre: one thyroid nodule; can be either inactive or active (toxic) – autonomously producing thyroid hormone.
• Multinodular goiter: multiple nodules can likewise be inactive or toxic, the latter is called a toxic multinodular goiter and associated with hyperthyroidism. These nodules grow up at varying rates and secrete thyroid hormone autonomously, thereby suppressing TSH-dependent growth and function in the rest of the gland. Inactive nodules in the same goiter can be malignant. Thyroid cancer is identified in 13.7% of the patients operated for multinodular goiter.
• Diffuse goiter: the whole thyroid appearing to be enlarged due to hyperplasia.

Size

• Class I: the goiter in normal posture of the head cannot be seen; it is only found by palpation.
• Class II: the goiter is palpable and can be easily seen.
• Class III: the goiter is very large and is retrosternal (partially or totally lying below the sternum), pressure results in compression marks.

Since many things can make your thyroid swell, there are lots of types of goiters. A few of them are:

Endemic goiters. Sometimes called colloid goiters, these are caused by a lack of iodine in your diet. Your thyroid uses iodine to make its hormones.

A colloid goiter develops from the lack of iodine, a mineral essential to the production of thyroid hormones. People who get this type of goiter usually live in areas where iodine is scarce.

Few people get this kind of goiter in countries where iodine is added to table salt, like the United States.

Simple goiters, which happen when your thyroid gland doesn’t make enough hormones. The thyroid grows larger to make up for this.

Nontoxic goiter (sporadic)

The cause of a nontoxic goiter is usually unknown, though it may be caused by medications like lithium. Lithium is used to treat mood disorders such as bipolar disorder. Certain drugs and medical conditions can trigger them.

Nontoxic goiters don’t affect the production of thyroid hormone, and thyroid function is healthy. They’re also benign.

Multinodular goiters, which happen when lumps called nodules to grow in your thyroid.

A goiter is described as “toxic” when it’s linked to hyperthyroidism. That means your thyroid makes too much thyroid hormone. A “nontoxic” goiter doesn’t cause either hyperthyroidism or hypothyroidism (not enough thyroid hormone).

This type of goiter forms one or more small nodules as it enlarges. The nodules produce their own thyroid hormone, causing hyperthyroidism. It generally forms as an extension of simple goiter.

How is a goiter diagnosed?

A healthcare professional may diagnose a goiter through a physical examination of the neck, palpating for swelling. They may ask the person to swallow while feeling for a goiter.

If they suspect a goiter, they may recommend further tests to determine any underlying problems with thyroid function, such as hyperthyroidism or hypothyroidism.

Thyroid function tests are blood tests that measure levels of thyroid-stimulating hormone (TSH) and thyroxine. A carefully controlled feedback mechanism means that TSH stimulates the thyroid to produce more thyroxine, while T4 tells the thyroid to stop producing as much thyroxine.

With an overactive thyroid, TSH levels are low or non-existent, and T4 levels are high. In people with an underactive thyroid, the reverse is true. TSH levels are high and T4 levels are low.

In some cases, such as suspected Graves’ disease, healthcare professionals may test for another hormone, triiodothyronine.

Often, your doctor will diagnose your goiter simply by examining your neck. You may then have tests to find out what caused it and how it affects you. They include:

Your doctor will check for the neck for swelling. They’ll also order a number of diagnostic tests that include these below:

Blood tests

Blood tests can detect changes in hormone levels and increased production of antibodies, which are produced in response to an infection or injury or overactivity of an immune system. Antibodies are proteins your body makes to fight infection.

Thyroid scan

Your doctor may order scans of your thyroid. This is usually done when your thyroid level is elevated. These scans show the size and condition of your goiter, overactivity of some parts of the whole thyroid.

Ultrasound

Ultrasound to see how large your thyroid is and whether you have nodules, an ultrasound produces images of your neck, the size of your goiter, and whether there are nodules. Over time, an ultrasound can track changes in those nodules and the goiter.

Biopsy

A biopsy is a procedure that involves taking small samples of your thyroid nodules if present. The samples are sent to a laboratory for examination. A biopsy, where your doctor uses a thin needle to take a sample of tissue or fluid for testing. This is used to rule out cancer.

A CT scan or MRI if your goiter is large or has spread to your chest.

They may also recommend special tests, such as:

• Radioactive iodine scan: This provides a detailed picture of the gland following an injection of radioactive iodine.
• Ultrasound scan: This assesses the gland and the size of the goiter.
• Fine-needle aspiration: A doctor may perform a biopsy to remove a sample of cells from within the gland if, for example, they suspect cancer.

Risk factors Of Goiters:-

Goiters can affect anyone. They may be present at birth and occur at any time throughout life.

Some common risk factors for goiters include:

• A lack of dietary iodine. People living in areas where iodine is in short supply and who don’t have access to iodine supplements are at high risk of goiters.
• Being female. Because women are more prone to thyroid disorders, they’re also more likely to develop goiters.
• Your age. Goiters are more common after age 40.
• Medical history. A personal or family history of the autoimmune disease increases your risk.
• Pregnancy and menopause. For reasons that aren’t entirely clear, thyroid problems are more likely to occur during pregnancy and menopause.
• Certain medications. Some medical treatments, including the heart drug amiodarone (Pacerone, others) and the psychiatric drug lithium (Lithobid, others), increase your risk.
• Radiation exposure. You are risk increases if you’ve had radiation treatments to your neck or chest area or you’ve been exposed to radiation in a nuclear facility, test, or accident.

You have a higher risk of developing a goiter if you:

• Are a woman
• Have a family history of autoimmune diseases
• Are older than 40
• Smoke cigarettes
• Have ever received radiation therapy in your neck or chest area
• Are pregnant or going through menopause
• Take certain medicines, including immunosuppressants, antiretrovirals, the heart drugs Cordarone or Pacerone (amiodarone), or the psychiatric drug Lithobid (lithium)

Treatment of a Goiter

Goiter is treated according to the cause. If the thyroid gland is producing an excess of thyroid hormones (T3 and T4), radioactive iodine is given to the patient to shrink the gland. If the goiter is caused by iodine deficiency, small doses of iodide in the form of Lugol’s iodine or KI solution are given. If the goiter is associated with an underactive thyroid, thyroid supplements are used as treatment. Sometimes a partial or complete thyroidectomy is required.

Some types of goiter may go away without treatment, but it is important to have your doctor make that determination.  The type of treatment that you receive depends on the cause, size, symptoms, and type of your goiter.  Taking iodine or potassium iodide may help people with an iodine deficiency.  Thyroid hormones may help to reduce your goiter and treat thyroid disorders. 

Radioactive iodine therapy is controversial.  Surgery, a thyroidectomy, is used to remove the thyroid if other treatments fail, if the goiter is causing compression, or if cancer is present.  Following radioactive iodine therapy or surgery, people will need to take thyroid hormone replacements for life.

When the patient presents with a normal blood level of thyroid hormone, such as is the case with multinodular goiter, no treatment is required. Nonetheless, patients are advised to keep having their condition monitored since their risk of developing thyroid disease is greater than that of the general population. If the gland is enlarged to the degree that it constricts air passages, surgical removal may be necessary.

Goiter treatment depends on the size of the goiter, your signs and symptoms, and the underlying cause. Your doctor may recommend:

• Observation. If your goiter is small and doesn’t cause problems, and your thyroid is functioning normally, your doctor may suggest a wait-and-see approach.
• Medications. If you have hypothyroidism, thyroid hormone replacement with levothyroxine (Levoxyl, Synthroid, Tirosint) will resolve the symptoms of hypothyroidism as well as slow the release of thyroid-stimulating hormone from your pituitary gland, often decreasing the size of the goiter.

For inflammation of your thyroid gland, your doctor may suggest aspirin or a corticosteroid medication treat the inflammation. If you have a goiter that is associated with hyperthyroidism, you may need medications to normalize hormone levels.

• Surgery. Removing all or part of your thyroid gland (total or partial thyroidectomy) is an option if you have a large goiter that is uncomfortable or causes difficulty breathing or swallowing, or in some cases, if you have a nodular goiter causing hyperthyroidism.

Surgery is also the treatment for thyroid cancer.

You may need to take levothyroxine after surgery, depending on the amount of thyroid removed.

• Radioactive iodine. In some cases, radioactive iodine is used to treat an overactive thyroid gland. The radioactive iodine is taken orally and reaches your thyroid gland through your bloodstream, destroying thyroid cells. The treatment results in the diminished size of the goiter but eventually may also cause an underactive thyroid gland.

Lifestyle and home remedies

If your goiter is caused by your diet, these suggestions can help:

• Get enough iodine. To ensure that you get enough iodine, use iodized salt or eat seafood or seaweed sushi is a good source of seaweed about twice a week. Shrimp and other shellfish are particularly high in iodine. If you live near the coast, locally grown fruits and vegetables are likely to contain some iodine, too, as are cow’s milk and yogurt.

Everyone needs about 150 micrograms of iodine a day (the amount is slightly less than half a teaspoon of iodized salt). But adequate amounts are especially important for pregnant and lactating women and for infants and children.

• Avoid excess iodine consumption. Although it’s uncommon, getting too much iodine sometimes leads to a goiter. If excess iodine is a problem, avoid iodine-fortified salt, shellfish, seaweed, and iodine supplements.

Treatment for a goiter includes:

• Close observation
• Medication
• Surgery
• Radiofrequency ablation (RFA)

If your goiter is not causing any symptoms, your doctor may recommend close observation to monitor for any changes or growth over time. Medication to normalize abnormal thyroid hormone levels may be helpful in decreasing the size of the goiter. Surgery is typically recommended for a goiter that’s causing symptoms. A portion of the enlarged thyroid, if possible, or all of the thyroids may need to be removed in a surgical procedure known as a thyroidectomy. 

When the goiter is caused by a noncancerous thyroid nodule(s), a new technique, called radiofrequency ablation (RFA), may be used to shrink the goiter and alleviate pressure-related symptoms, without the need for surgery. 

Preparing for an appointment

If you’ve been diagnosed with a goiter, you’re likely to have further tests to determine the cause. You might find it helpful to make a list of questions to ask your doctor, such as:

• What caused this goiter to develop?
• Is it serious?
• What can be done to treat the underlying cause?
• I have these other health conditions. How can I best manage them together?
• What are the alternatives to the main treatment that you’re proposing?
• What will happen if I choose to do nothing?
• Will the goiter continue to get larger?
• Will the treatment you’re suggesting improve the appearance of the goiter?
• Will I have to take medication? For how long?

For other thyroid conditions underlying the development of a goiter, hormone replacement, radiation, or surgery may be necessary.

Goiter Removal

If you require surgery to remove the goiter, your surgeon will determine the best approach for removal.  Some or all of the thyroid may be removed via a scarless technique.  If a neck incision must be made, the smallest incision possible will be used to allow for safe removal of the affected thyroid gland.

If the goiter extends underneath the breastbone significantly, a small cut in your breastbone may need to be made to safely remove it. This typically requires an experienced thyroid surgical team to optimize outcomes. 

Complications of goiters

Small goiters that don’t cause physical or cosmetic problems aren’t a concern. But large goiters can make it hard to breathe or swallow and can cause a cough and hoarseness.

• Progressive thyroid enlargement or the development of hardened nodules may mean thyroid malignancy. All thyroid nodules should be biopsied to check for cancer.
• A simple goiter may progress to a toxic nodular goiter.
• Hypothyroidism may occur after the treatment of a large goiter with radioactive iodine or surgery.

Goiters that result from other conditions, such as hypothyroidism or hyperthyroidism, may be associated with a number of symptoms, ranging from fatigue and weight gain to unintended weight loss, irritability, and trouble sleeping.

Certain conditions associated with goiters may cause the thyroid gland to stop producing hormones and result in hypothyroidism.  Alternatively, a goiter may be toxic and cause the thyroid gland to produce too much hormone, resulting in hyperthyroidism.  Such conditions are usually treated with lifelong thyroid medications.

Prevention:
The use of iodized table salt prevents endemic goiter.

Summary Of goiter

A goiter is a swelling of the thyroid gland. It is often harmless, though it can signal an underlying thyroid condition.

Depending on its cause, a goiter may go away without treatment. Doctors may recommend treatments if there is underlying thyroid disease, or if the goiter gets in the way of a person’s daily life.

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