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Thyroid Guide


Goiter

Goiter

General Overview
Enlargement of the thyroid gland is known as goiter. The thyroid is a small butterfly-shaped gland, which rests in the lower neck. Its main function is to control your body's growth and metabolism. To control metabolism, your thyroid gland produces hormones (thyroxine [T4] and triiodothyronine [T3]). A properly functioning thyroid will produce the right amount of hormones required to keep your body functioning normally. The level of thyroid hormones in the blood is controlled by your pituitary gland.
You can develop goiter, if you have hyperthyroidism (overactive thyroid gland), hypothyroidism (underactive thyroid gland), or even a normally functioning thyroid gland. Endemic goiter is an important public health problem in India. It is more prevalent along the southern slopes of the Himalayas. Isolated pockets of endemicity exist in Chota Nagpur plateau, Arawali range, Eastern and Western ghats. However, the incidence has comedown considerably following the introduction of compulsory iodization of table salt as part of the National Goiter Control Programme. In India, about 167 million people are under the risk of developing iodine deficiency and 54.4 million people have goiter.
Introduction
What is goiter? Are there different types of goiter?
Goiter is the enlargement of the thyroid gland. If you have goiter, it only indicates that you are having a condition, which can cause abnormal growth of the thyroid gland. Goiters can be simple, hereditary, or caused by other conditions.
Simple goiters can be endemic goiter (colloid) or sporadic (nontoxic) goiter. You can develop simple goiter, if your thyroid gland does not produce adequate amount of the thyroid hormones to meet your body needs. Endemic goiter on the other hand is more common in people whose diet is deficient in iodine. It is more common in certain geographic regions, where there is deficiency of iodine in the soil. It is also common among those who live away from coastal regions. Your thyroid gland tries to compensate for the iodine deficiency by enlarging. The cause of sporadic goiter is not known. It could be due to certain drugs like lithium or aminoglutethimide.
Goiters can be hereditary. You are more prone to develop goiter, if you are a female, above 40 years of age or if any body in your family has goiter. Goiter can also be caused by hypothyroidism, hyperthyroidism, thyroid cancer, pregnancy, thyroiditis (inflammation of the thyroid gland), toxic nodular goiter, and radiation exposure.
Signs and Symptoms
How do I know that I have goiter?
Your symptoms can differ depending on the type of your goiter. The main symptoms of hyperthyroidism include:
  • a swelling in front of your neck just below your Adam's apple, which can vary in size from a small nodule to a large lump.
  • a feeling of stiffness in your throat area.
  • breathing difficulty, coughing, or wheezing.
  • swallowing difficulty.
  • hoarseness of your voice.
  • distension of the veins in your neck.
  • a feeling of dizziness, when you raise your hand above your head.
  • increase in your resting pulse rate.
  • fast heartbeat.
  • nausea, vomiting, and diarrhea.
  • tremors (shaking of the hands).
  • sweating even without an increase in the room temperature or doing exercise.
  • agitation.
If you have hypothyroidism, you can have the following symptoms.
  • A feeling of tiredness.
  • Constipation.
  • Dry skin.
  • Weight gain.
  • Irregular menstruation.
Causes
What are the causes of goiter?
Different causes of goiter include the following.
  • Unknown causes. Cause is not known in the case of sporadic goiter. This type of goiter can be due to the use of certain drugs like lithium or aminoglutethimide.
  • Inadequate supply of thyroid hormones. When your thyroid gland does not make the adequate amount of hormones to meet your body's needs, the gland tries to compensate for this deficiency by enlarging.
  • Deficiency of iodine. Iodine is necessary for making thyroid hormones. People living in some specific geographic areas fail to get the required amount of iodine from their diet and this result in endemic goiter.
  • Grave's disease. It is an autoimmune disease. Autoimmune disorder is a condition, in which antibodies stimulate thyroid tissue causing over production of the thyroid hormones, resulting in the swelling of your gland.
  • Hashimoto's disease. It is also an autoimmune disease, which causes inflammation of your thyroid gland, resulting in underproduction of the thyroid hormones. Other hormones of your body try to stimulate the thyroid gland causing it to enlarge.
  • Nodular goiter. Tissue growth occurs either on one or both sides of the thyroid gland which in turn can result in its enlargement.
  • Thyroid cancer. Cancer of the thyroid gland can cause enlargement of the gland.
  • Pregnancy. Human chorionic gonadotropin (hormone secreted during pregnancy) can lead to the enlargement of the thyroid gland.
  • Thyroiditis. Enlargement of the thyroid gland can occur due to inflammation. It can be the result of viral disease or pregnancy.
  • Exposure to radiation. Previous radiation treatment on your neck increases your risk of goiter.
Risk Factors
Find out if you are at risk of developing goiter
Your risk of developing goiter depends on the following.
  • Gender. Your risk of developing goiter is higher, if you are a female.
  • Age. You are at higher risk of developing goiter, if you are over 40 years of age.
  • Family history. Your risk increases, if any other family member has goiter.
  • Iodine deficiency. Your risk of developing goiter increases, if your diet is deficient in iodine.
  • Living in endemic areas. Your risk is higher, if you are living in an area, which is endemic for goiter.
Diagnosis and Screening
How will my doctor diagnose goiter?
To evaluate your condition, your doctor will ask you for a detailed medical and family history along with a physical examination.
Medical and family history:
Your doctor will question you about:
  • any family history of thyroid disease.
  • the presence of any symptoms that you may be having or have experienced.
  • whether you have undergone thyroid surgery or any radiation treatment on your neck.
  • medicines that you are currently taking or have taken earlier that could trigger goiter formation.
Physical examination:
Your doctor will conduct a thorough physical examination, during which he will:
  • check your thyroid gland.
  • look for the presence of any swelling in your face, arms, and legs.
  • look for changes in your skin and hair (dryness, brittleness, and coarseness).
  • check your pulse to calculate the rate at which your heart is beating.
  • check your reflexes for any change.
Should I undergo any tests for diagnosing goiter?
If your doctor on initial evaluation suspects goiter, he will advise you to undertake certain blood tests, imaging tests, and procedures for confirming the diagnosis.
Blood tests:
Thyroid-stimulating hormone (TSH) test: Thyroid-stimulating hormone is a hormone produced by the pituitary gland, which regulates the production and release of the hormones T4 and T3 from the thyroid gland. A marked increase in the level of TSH will mean hypothyroidism and a reduction in the level of this hormone indicates hyperthyroidism. During this test, the blood is collected from a vein, usually from the inside of your elbow or the back of your hand. As some drugs can alter the results, your doctor may advise you to stop them before the test. Your normal TSH levels will range between 0.4 mIU/L to 4.0 mIU/L. If you are undergoing treatment for any thyroid disorder, your TSH level should lie in the range of 0.5 mIU/L to 3.0 mIU/L.
Thyroxine (T4) test: Thyroxine is a hormone produced by the thyroid gland. This test is done to determine, if your thyroid gland is functioning properly. During this test, the blood is collected from a vein, usually from the inside of your elbow or the back of your hand. As some drugs can alter the results, your doctor may advise you to stop them before the test. Your normal T4 levels will range between 4.5 mcg/dL to 11.2 mcg/dL.
Triiodothyronine (T3) test: Triiodothyronine is a hormone produced by the thyroid gland. This test is done to determine, if your thyroid gland is functioning properly. During this test, the blood is collected from a vein, usually from the inside of your elbow or the back of your hand. As some drugs can alter the results, your doctor may advise you to stop them before the test. Your normal T3 levels will range between 100 ng/dL to 200 ng/dL.
Antithyroid antibodies: Your doctor may recommend this test to follow-up the other thyroid test results (T4, T3, and/or TSH) that show signs of thyroid dysfunction and/or for investigating the cause of goiter. During this test, the blood is collected from a vein, usually from the inside of your elbow or the back of your hand. There is no standard reference range for this test. Presence of thyroid antibodies indicates that you have an autoimmune thyroid disease. The higher the level of antibodies, the greater is your chance of having autoimmune thyroid disease. Increasing antibody level rather than stable level is more significant.
Imaging tests:
Ultrasound of the thyroid: This is an imaging test, which helps in assessing the size of your thyroid gland. It helps to detect the enlargement of your gland.
Thyroid scan: This is another imaging test, which gives information regarding the size and function of your thyroid gland. This test is performed after injecting a small amount of radioactive substance into your vein.
Computed tomography or magnetic resonance imaging scan: These are imaging tests that are done to determine the size and extent of your goiter.
Barium swallow: This test is done to assess, if your goiter is pressing on your esophagus (food pipe) and causing difficulty in swallowing.
X-ray of the neck and chest: This is done, in case your goiter is very large for determining, if your thyroid is compressing your trachea (windpipe).
Procedures:
Fine needle aspiration biopsy: This test may be required, if there are large nodules in your thyroid. In this test, a small needle is inserted into your thyroid gland for taking a sample tissue. This sample is later examined under the microscope for detecting any abnormality.
Treatment
How is goiter treated?
Your doctor will treat your condition based on the degree of enlargement of your thyroid gland, your symptoms, and also on the underlying cause for your goiter. The treatments that your doctor might consider include the following.
Watchful waiting:
You may not need any treatment, if your goiter is very small and it does not cause trouble you. Your doctor will however continue to watch your condition for detecting any changes.
Medications:
  • Levothyroxine. If your goiter is due to hypothyroidism, your doctor may give you levothyroxine, which is a type of thyroid hormone replacement therapy. He may suggest other medicines, if your thyroid is hyperactive.
  • Aspirin. If your goiter is caused by inflammation of the thyroid gland, your doctor may prescribe aspirin or corticosteroids.
  • Iodine. If your goiter is due to iodine deficiency, your doctor will prescribe small doses of iodine either in the form of Lugol's iodine or potassium iodide.
Radioactive iodine treatment:
If you have hyperthyroidism, your doctor may recommend radioactive iodine treatment, which kills the thyroid cells leading to the shrinking of your gland. This treatment should be followed by hormone replacement therapy for life.
Surgery:
If your goiter is large and causes difficulty in swallowing or breathing, you may have to undergo surgery to remove a part or the whole of thyroid gland. Your doctor may also recommend surgery for removing the nodules, especially in the presence of cancer. You may be required to take lifelong thyroid hormone replacement therapy based on the amount of thyroid gland that is removed.
Self Care and Lifestyle Change
Some measures that will help in preventing goiter include:
  • using iodized salt in your diet, especially if you are living in an endemic area.
  • increasing the intake of more iodine-rich food like fish, seafood, and sea vegetables, in case of iodine deficiency.
  • reducing the intake of broccoli, cabbage, Brussels sprouts, cauliflower, kale, spinach, turnips, soy, beans, and mustard greens, as they interfere with your thyroid function.
  • increasing the intake of more food items containing omega-3-fatty acids will help in reducing inflammation over a period of time.
  • having a proper nutritious diet and healthy water supply.
References