GOITER

Definition

A goiter is an enlargement of your thyroid gland. It is the gland at the front of the neck just
below the Adam's apple.

It may be a temporary problem that will get better without treatment. Or it can be a
symptom of another, possibly serious, thyroid condition that requires medical attention.

Signs and symptoms

 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

Pathophysiology

The thyroid gland is controlled by thyroid-stimulating hormone (TSH; also known as

thyrotropin), secreted from the pituitary gland, which in turn is influenced by the
thyrotropin-releasing hormone (TRH) from the hypothalamus. TSH permits growth, cellular
differentiation, and thyroid hormone production and secretion by the thyroid gland.
Thyrotropin acts on TSH receptors located on the thyroid gland. Thyroid hormones are
synthesized from iodination of tyrosine. The iodine is transported from plasma into the
thyroid cell via a sodium-iodide symporter. This is an active process resulting in an
intracellular iodine level exceeding 20 times the plasma iodine level. This iodine transport
activity is controlled by TSH. Serum thyroid hormones levothyroxine and triiodothyronine
feed back to the pituitary, regulating TSH production. Interference with this TRH-TSH thyroid
hormone axis causes changes in the function and structure of the thyroid gland. Stimulation
of the TSH receptors of the thyroid by TSH, TSH-receptor antibodies, or TSH receptor
agonists, such as chorionic gonadotropin, may result in a diffuse goiter. When a small group
of thyroid cells, inflammatory cells, or malignant cells metastatic to the thyroid is involved, a
thyroid nodule may develop.

A deficiency in thyroid hormone synthesis or intake leads to increased TSH production.

Increased TSH causes increased cellularity and hyperplasia of the thyroid gland in an
attempt to normalize thyroid hormone levels. If this process is sustained, a goiter is
established. Causes of thyroid hormone deficiency include inborn errors of thyroid hormone
synthesis, iodine deficiency, and goitrogens.

A goiter may result from a number of TSH receptor agonists. TSH receptor stimulators
include TSH receptor antibodies, pituitary resistance to thyroid hormone, adenomas of the
hypothalamus or pituitary gland, and tumors producing human chorionic gonadotropin.

Diagnostic examination

 Physical exam- doctor may discover an enlarged thyroid gland simply by feeling your
neck and having you swallow during a routine physical exam. In some cases, doctor
may also be able to feel the presence of nodules.
 Hormone test. Blood tests can determine the amount of hormones produced by
your thyroid and pituitary glands. If your thyroid is underactive, the level of thyroid
hormone will be low. At the same time, the level of thyroid-stimulating hormone
(TSH) will be elevated because your pituitary gland tries to stimulate your thyroid
gland to produce more thyroid hormone. A goiter associated with an overactive
thyroid usually involves a high level of thyroid hormone in the blood and a lower-
than-normal TSH level.
 Antibody test. Some causes of a goiter involve production of abnormal antibodies. A
blood test may confirm the presence of these antibodies.
 Ultrasonography. A wand-like device (transducer) is held over your neck. Sound
waves bounce through your neck and back, forming images on a computer screen.
The images reveal the size of your thyroid gland and whether the gland contains
nodules that your doctor may not have been able to feel.
  Thyroid scan. During a thyroid scan, a radioactive isotope is injected into the vein on
the inside of your elbow. You lie on a table with your head stretched backward while
a special camera produces an image of your thyroid on a computer screen. The time
needed for the procedure may vary, depending on how long it takes the isotope to
reach your thyroid gland. Thyroid scans provide information about the nature and
size of your thyroid, but they're more invasive, time-consuming and expensive than
ultrasound tests.
 Biopsy. During a fine-needle aspiration biopsy, ultrasound is used to guide a needle
into your thyroid to obtain a tissue or fluid sample for testing

Medical intervention

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

 Observation. If the goiter is small and doesn't cause problems, and the thyroid is
functioning normally, doctor may suggest a wait-and-see approach.
 Medications. If a patient has 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 the
pituitary gland, often decreasing the size of the goiter. For inflammation of thyroid
gland, doctor may suggest aspirin or a corticosteroid medication to treat the
inflammation. If a patient has a goiter that is associated with hyperthyroidism, it may
need medications to normalize hormone levels.
 Surgery. Removing all or part of the thyroid gland (total or partial thyroidectomy) is
an option if the patient has a large goiter that is uncomfortable or causes difficulty
breathing or swallowing, or in some cases, if it has a nodular goiter causing
hyperthyroidism. Surgery is also the treatment for thyroid cancer. A patient 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 the thyroid gland
 through the bloodstream, destroying thyroid cells. The treatment results in a
diminished size of the goiter, but eventually may also cause an underactive thyroid
gland.

Medication

 Thyroid hormone replacement with levothyroxine (Levoxyl, Synthroid, Tirosint)

- This will resolve the symptoms of hypothyroidism as well as slow the release
of thyroid-stimulating hormone from the pituitary gland, often decreasing the
size of the goiter
 Aspirin or a corticosteroid medication
- For inflammation of thyroid gland.

Reference:

Goiter - Symptoms and causes - Mayo Clinic

What Is a Goiter? What Causes Goiters? (webmd.com)

Goiter Treatment & Management: Medical Care, Surgical Care, Consultations (medscape.com)