Goiter Latest Facts: Causes, Diagnosis, Symptoms, Risk Factors, Prevention and Treatment

A goiter can be described as an excessive enlargement of the thyroid gland. The thyroid gland usually weighs 20 to 30 grams and is located at the base of the neck and consists of two lobes. It produces thyroid hormones, which are essential for many processes that ensure the proper functioning of the body.

Various factors can cause it to enlarge and form goiter:

  • Homogeneous: the increase in volume is then regular and affects one or both lobes.
  • Heterogeneous: only one or more areas of the thyroid gland are larger and form one or more nodules, hence the term nodular or multinodular goiter is used.

Goiter. Image Courtesy of Drahreg01

Goiter is not a disease in itself and can occur as a symptom in many health conditions.

A goiter can become a problem because of its size, but especially because of thyroid disorders such as hypothyroidism, hyperthyroidism, and cancer. The cancer of the thyroid gland rarely manifests as a goiter.

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What are the symptoms of goiter?

A goiter can be identified by swelling at the base of the neck, which may be painful, rapid, or progressive, or by signs of poor thyroid function. The swelling at the base of the neck may be noticed by the person himself or discovered by the doctor on palpation of the base of the neck.

Nowadays and in the US, it is rare for a goiter to be so large that it causes difficulty eating, breathing, or a change in voice. In the past, however, it could happen if people did not seek immediate treatment.

In some cases, the palpation of the goiter can cause pain.

If associated with hyperthyroidism (overproduction of thyroid hormones), it can cause weight loss, tachycardia (increased heart rate), tremors, anxiety or nervousness, excessive sweating, a constant feeling of heat, diarrhea, etc.
Conversely, in hypothyroidism (deficiency of thyroid hormones), the face may be swollen, with weight gain, coldness, mental malaise or even depression, fatigue, constipation, slowing of the pulse, etc.

When to see a doctor

If there is swelling at the base of the neck, pain when touching this area, unexplained weight changes, behavioral changes, you should seek medical attention. After a medical examination, the doctor may refer the person suffering from goiter to an endocrinologist, an ear, nose, and throat specialist, or, if necessary, a surgeon.

What causes goiter?

There are many different causes of goiter depending on whether it is homogeneous or heterogeneous, with or without abnormalities in thyroid function. It may be related to:

  • Nutritional, genetic, and hormonal factors (hence they are more common in women).
  • Smoking, which promotes the development of goiter by competing with iodine.
  • Exposure to radiation, cervical radiation in childhood, or environmental exposure.

Homogenous goiter

These are goiters in which the thyroid gland is homogeneously swollen throughout its entire volume.
Homogeneous goiter with normal thyroid function occurs in 80% of cases in women. It is painless, variable in size, and does not require special treatment.

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Hyperthyroidism or Graves’ disease

More common in women than men and often hereditary in origin, accompanied by weight loss, irritability, fever, excessive sweating, and tremors. In some cases, exophthalmos, i.e. enlarged eyeballs giving the impression of bulging eyes protruding from the orbit.

Homogenous goiter with hypothyroidism

Also more common in women. It can be caused by drugs such as lithium or by iodine deficiency. Before the use of iodine-enriched table salt, it was widespread. It can also be hereditary or caused by an autoimmune disease (Hashimoto’s Disease) in which the body makes antibodies against its own thyroid gland.

Iodine excess

X-rays with contrast medium or treatment with amiodarone (a drug for cardiac arrhythmia) can lead to hypo- or hyperthyroidism. In the first case, they disappear spontaneously, and in the second case after discontinuation of amiodarone.

Painful goiters accompanied by fever

May be due to a subacute de Quervain’s thyroiditis, which can lead to hypothyroidism and often to hyperthyroidism. It usually disappears spontaneously within a few weeks or months. The doctor may prescribe NSAIDs such as ibuprofen or even corticosteroids if the condition is painful. Likewise, doctors may also prescribe heart medications to slow the heart in case of tachycardia.

Nodular goiter (Heterogeneous)

Through palpation or the use of ultrasound the doctor can look for the presence of nodules, which may or may not be associated with abnormal thyroid function. The nodule(s) may be “neutral” with normal hormone function, “cold”  hypoactive with decreased levels of thyroid hormone secretion, or hyperactive “hot”  with increased thyroid hormone secretion. Hot nodules are exceptionally carcinogenic. However, cold nodules, whether solid, liquid or mixed, may correspond to a malignant tumor, i.e. cancer, in 10 to 20% of cases.

Which doctor should I consult if I have a goiter?

In the case of goiter, i.e. enlargement of the thyroid gland at the base of the neck, the family doctor can be consulted, who will refer the patient to an endocrinologist or an ENT doctor, depending on the examination and the original elements.

Clinical examination

Examination of the neck by the doctor will allow him to determine whether the swelling at the base of the neck is related to the thyroid gland. It can also show whether the swelling is painful or not, whether it is homogeneous or not, whether it affects one or both lobes, and whether the consistency is hard, firm, or soft. The doctor will also look for the presence of lymph nodes in the neck during the examination.

During the general medical examination, the doctor looks for signs of abnormal thyroid function by asking questions in combination with a physical examination.

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The doctor will also ask what treatment the person usually undergoes, whether there is a family history of thyroid problems, childhood neck irradiation, geographic origin, favorable factors (smoking, iodine deficiency, pregnancy).

Biological testing

They analyze thyroid function by measuring thyroid hormones (T3 and T4) and TSH (a hormone produced by the pituitary gland that regulates the secretion of thyroid hormones). In practice, TSH is mainly measured at the initial assessment. An elevated TSH means that the thyroid is not working properly, a low TSH means that thyroid hormone secretion is too high.

The doctor may also order a biological test to detect the presence of antibodies.

Radiological examinations

The basic examination is an ultrasound to determine the size, whether the goiter is heterogeneous or not, the characteristics of the nodule(s) (fluid, solid or mixed), its exact localization, and, in particular, its extension into the chest (the so-called “invaded goiter”). It also examines the lymph nodes in the neck.

Scintigraphy of the thyroid gland

In this examination, the person being examined is given radioactive markers containing a substance that binds to the thyroid gland (iodine or technetium). As these markers are radioactive, it is easy to get a picture of the areas where the markers have been injected. This examination provides information on the overall function of the thyroid gland. It can reveal nodules that are not visible by palpation, and can also show:

  • If the nodules are “cold”: they bind very little of the radioactive tracer, which is a sign of reduced thyroid hyperfunction.
  • If the nodules are “hot”, they bind a large amount of radioactive tracer, indicating overproduction.
  • If the nodules are neutral, they detect moderate amounts of radioactive tracers, indicating normal hormonal function.

Nodal puncture is used to detect the presence of malignant cells or to evacuate a cyst. It is performed systematically on all cold nodes.

Regular X-rays may show calcification of the goiter and its enlargement towards the thorax.

Magnetic resonance imaging is used to clarify the extension of the thyroid gland towards adjacent structures and, to determine the location of lymph nodes.

What are the risks of not treating the goiter?

A small goiter that does not show changes in hormonal function or nodules on ultrasonography should not be treated, but monitoring how it progresses is necessary.

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Complications of the goiter may be related to its volume: voice changes with vocal cord paralysis, difficulty swallowing or breathing, venous compression, etc.

Complications related to hormonal dysfunction, if uncorrected, can lead to generalized manifestations:

  • Hyperthyroidism: weight loss, tachycardia, tremor, anxiety, irritability, excessive sweating, heat intolerance, diarrhea…
  • Hypothyroidism: weight gain, coldness, depression, fatigue, constipation, slowing of pulse…

Complications of thyroid cancer include spread to neighboring organs (larynx, throat, skin, lymph nodes) or distant spread (metastases).

How is goiter treated?

Depending on the cause of goiter, several types of treatment can be used.

Treatment is with medication and/or surgery, but some goiters only require observation.

Treatment with thyroid hormones corrects hypothyroidism.

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Thyroid medication is prescribed for simple goiters that produce too much thyroid hormone. Their aim is to reduce hormone secretion and normalize the size of the goiter.

Iodine-131 (radioactive iodine) therapy is used to reduce large goiters. Radioactive iodine is taken up by thyroid cells which are then destroyed by exposure to its radioactivity.

Partial or total removal (thyroidectomy): the thyroid gland can be surgically removed partially or completely. If the thyroid gland is completely removed, it is necessary to take thyroid hormones for life to replace the hormones that the body can no longer produce. This surgery is indicated if there is compression of neighboring organs if thyroid cancer is suspected.

In some cases, the formation of goiters can be prevented. The lack of iodine in tap water in some regions has to be compensated by the use of iodized salt or even iodide tablets.

Treatments that may affect the thyroid should be monitored for cancer or thyroid hormone abnormalities.

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