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 The term goiter (from the Latin gutter = the throat) is used to describe generalized

enlargement of the thyroid gland.
 A discrete swelling (nodule) in one lobe with no palpable abnormality elsewhere is termed
an isolated (or solitary) swelling. Discrete swellings with evidence of abnormality
elsewhere in the gland are termed dominant.
Deficiency of circulating thyroid
Iodine deficiency
hormone due to the deficiency
(Most common)
of inborn errors of metabolism (Daily requirement: 0.10.15mg)
1. Very low iodide content in
the water and food
2. Although iodides in food
and water may be adequate,
failure of intestinal absorption
EXCESSIVE RELEASE OF
THYROID STIMULATING
HORMONE (TSH)
 The natural history of simple goiter
Stages in goiter formation are:
• Persistent growth stimulation causes diffuse hyperplasia; all
lobules are composed of active follicles and iodine uptake is

Goitrogenic agents
1. The vegetables of the
brassica family (cabbage,
kale and rape), which contain
thiocyanate
2. Drugs such as paraaminosalicylic acid (PAS) and
the antithyroid drugs.
3. Consumption of iodine in
large quantities
Improper synthesis of thyroid
and
hormones Thiocyanates
results in defective
interfere with
negativeperchlorates
feedback mechanism
to
iodide
trapping;
carbimazole
the anterior pituitary
and thiouracil compounds
interfere with the oxidation of
iodide and the binding of
iodine to tyrosine

Hyperplasia represents the response of the thyroid to TSH, other growth factors, or circulating
stimulatory antibodies. The hyperplasia may compensate for thyroid hormone deficiency. The
epithelium is tall and columnar; the follicles are collapsed and contain only scanty
colloid. When the hyperplastic stage is extreme and prolonged, there may be confusion with
carcinoma because of the degree of cellularity and the presence of enlarged cells. The nuclei
are enlarged, hyperchromatic, and even bizarre. Because of follicular collapse and epithelial
hyperplasia and hypertrophy, papillary changes can be seen.
uniform. This is a diffuse hyperplastic goiter, which may persist for a long time but is reversible
if stimulation ceases.

• Later, as a result of fluctuating stimulation, a mixed pattern develops with areas of active
lobules and areas of inactive lobules.
Thyroid follicles may not remain in a state of continuous hyperplasia, but instead undergo
involution, with the hyperplastic follicles re-accumulating colloid. The epithelium becomes
low cuboidal or flattened and resembles that of the normal gland. Some follicles become
much larger than normal, contain excessive colloid, and are lined with flat epithelium. The
gland is diffusely enlarged, soft, and has a glistening cut surface because of the excess of
stored colloid. In addition to large follicles filled with colloid, there are foci in the gland where
hyperplasia is still evident.This phase of nontoxic goiter is often termed colloid goiter.

.  Although the nodular stage of simple goiter is irreversible.to exclude mild hyperthyroidism 2. or some form of partial resection.15–0. the nodules are palpable and often visible. FNAC is only required for a dominant swelling in a generalized goiter.  Subtotal thyroidectomy involves partial resection of each lobe. may simulate carcinoma. they are smooth. and the goiter is painless and moves freely on swallowing. usually firm and not hard. The vascular network is altered through the elongation and distortion of vessels. A painful nodule. as is the presence of a dominant area of enlargement that may be neoplastic. Growth of goiters therefore may be related to focally excessive stimulation by TSH. and active follicles are present only in the internodular tissues. or rapid enlargement of a nodule raises suspicion of carcinoma but is usually due to hemorrhage into a simple nodule. Because the nodules distort the vascular supply to some areas of the gland. Most nodules are inactive.  There is a choice of surgical treatment in multinodular goitre: total thyroidectomy with immediate and lifelong replacement of thyroxine. Patients with long-standing thyroid deficiency typically develop nodular goiters that result from over distention of some involuted follicles. leaving up to 8 g of relatively normal tissue in each remnant. necrosis. sudden appearance. Ultrasound and CT give more detailed images but rarely influence clinical management. stimulation by Necrotic lobules coalesce to form nodules filled either with iodine-free colloid or a mass of new but inactive follicles. • Continual repetition of this process results in a nodular goiter. and in their responsiveness to TSH. due to calcification. removing the bulk of the gland. a hyperplastic goiter may regress if thyroxine is given in a dose of 0.  Operation may be indicated on cosmetic grounds.2 mg daily for a few months.  Treatment  In the early stages. The patient is euthyroid. leading to hemorrhage. inflammation. some zones will contain larger-than-normal amounts of colloid and/or iodide. to conserve sufficient functioning thyroid tissue to subserve normal function while reducing the risk of hypoparathyroidism that accompanies total thyroidectomy. for pressure symptoms or in response to patient anxiety. in their capacity for growth and function. and persistence of regions of epithelial hyperplasia. These localized degenerative and reparative • changes produce some nodules that are poorly circumscribed. and others that are well demarcated and resemble true adenomas. and others will have relative colloid and/or iodide deficiency.  Diagnosis Diagnosis is usually straightforward. the presence of circulating thyroid antibodies tested to differentiate between autoimmune thyroiditis 3. more than half of benign nodules will regress in size over ten years. Differential diagnosis from autoimmune thyroiditis may be difficult and the two conditions frequently coexist. Plain radiographs of the chest and thoracic inlet will rapidly demonstrate clinically significant tracheal deviation or compression 4.  Most patients with multinodular goiter are asymptomatic and do not require operation. The new follicles form nodules and may be heterogeneous in their appearance. Thyroid function tests---.  Retrosternal extension with actual or incipient tracheal compression is also an indication for operation. Hardness and irregularity. 5. and fibrosis.  Investigations 1.• Active lobules become more vascular and hyperplastic until hemorrhage occurs. causing central necrosis and leaving only a surrounding rind of active follicles.

however. In many cases. particularly in older patients. Reoperation for recurrent nodular goiter is more difficult and hazardous and. reoperation and completion total thyroidectomy is straightforward if required for progression of nodularity in the remaining lobe. as are the postoperative complications. the causative factors persist and recurrence is likely. total lobectomy on the more affected side is the appropriate management with either subtotal resection (Dunhill procedure) or no intervention on the less affected side.   The technique is essentially the same as described for toxic goiter. when the first operation comprised unilateral lobectomy alone for asymmetric goiter. Total lobectomy and total thyroidectomy have the additional advantage of being therapeutic for incidental carcinomas . an increasing number of thyroid surgeons favor total thyroidectomy in younger patients. with one lobe more significantly involved than the other. the multinodular change is asymmetrically distributed. More often. for this reason. In these circumstances. However.