GOITER - SYMPTOMS, CAUSES AND DIAGNOSIS

Goiter is the medical condition when the thyroid gland in your neck is enlarged. The thyroid gland is a butterfly-shaped gland located in the middle part of your neck, right under your adam’s apple.

The thyroid gland is responsible for producing several hormones, mainly responsible for regulating your body’s metabolism. These hormones affect nearly all your organs and cells, controlling how they function and use energy.

When the thyroid gland gets enlarged for any reason, the condition is called “goiter.” Many medical conditions can cause your thyroid gland to get enlarged. A goiter can be associated with high, normal, or low levels of thyroid hormones depending on the underlying cause.

How the thyroid works

The thyroid produces two main hormones called T3 and T4. Thyroid hormones control metabolism, i.e., how your body cells use energy. For your thyroid to work, the pituitary gland (a gland located in your brain) needs to produce a hormone called TSH to stimulate the thyroid. TSH stands for “Thyroid Stimulating Hormone,” and it’s considered the best initial test used by doctors to assess for thyroid disease.

If your thyroid is not producing enough hormones, the pituitary will release TSH to stimulate production. TSH promotes thyroid cell growth and hormone production, causing the gland to become larger so that it can meet your body’s needs. This means that your T3 and T4 levels might be normal, even if you have a goiter. It all depends on the underlying condition.

What are the most common causes of goiter?

Numerous conditions can be responsible for developing goiter:

• Iodine deficiency: This is considered the leading cause of goiter worldwide. Iodine is a vital component for producing the thyroid hormone. When your diet does not have enough iodine, the thyroid is not able to produce enough T3 and T4. The pituitary gland produces TSH in response to try to get the thyroid gland to work harder. This causes the thyroid gland to grow to cause goiter. Iodine is added to table salt in many countries to overcome this problem.
• Hashimoto’s thyroiditis: This is an autoimmune disease in which the body attacks your thyroid cells. Hashimoto’s is the most common cause of hypothyroidism (low thyroid function) worldwide. Low thyroid hormones mean high TSH, just like in iodine deficiency, and eventually, patients develop a goiter.
• Grave’s disease: This is also an autoimmune disease. However, it causes hyperthyroidism (overactive thyroid), instead of hypothyroidism, as with Hashimoto’s thyroiditis. The autoimmune antibodies in Grave’s disease cause your thyroid to swell and produce abnormally high levels of hormones.
• Multinodular goiter: As the name suggests, a multinodular goiter is when multiple solid or fluid-filled nodules start growing in your thyroid gland, causing it to become large.
• Thyroid nodule: A single thyroid nodule can grow large enough to cause goiter. These can be either benign or malignant (cancerous).
• Thyroiditis: This is the inflammation of the thyroid, which usually happens after a viral illness or after giving birth, and resolves alone. Thyroiditis is generally painful.
• Pregnancy: The hormone HCG produced by the placenta during pregnancy can be responsible for thyroid growth.
• Thyroid cancer: Regardless of its shape, any tumor in the thyroid can cause a goiter.

Who is likely to develop a goiter?

The main risk factors for having a goiter are:

• Low dietary iodine
• Female gender (women are much more likely to have thyroid disorders)
• Age greater than 40
• Certain medications (like amiodarone and lithium)
• Exposure to radiation
• Menopause and pregnancy

What are the symptoms of goiter?

Other than the obvious neck mass that defines a goiter, this enlargement can cause several symptoms that would make treatment necessary even in the absence of hormonal disorders or suspicion of malignancy. These symptoms are generally related to “mass effect,” that is when the enlarged thyroid compresses the surrounding structures:

• Difficulty when swallowing
• Difficulty breathing
• Coughing
• Hoarseness of the voice
• Swelling of your neck veins
• Dizziness when you raise your arms above your head

Depending on the underlying cause, you might have symptoms related to hyperthyroidism or hypothyroidism. People who have hyperthyroid disorders such as Grave’s disease would have signs that indicate high metabolism, like a rapid heart rate, weight loss, tremors, agitation, diarrhea, and heat intolerance.

In people who have a hypothyroid disorder, you would expect the opposite: fatigue, weight gain, cold intolerance, and constipation.

How is goiter diagnosed?

You might notice the goiter yourself if it becomes large enough, or your general practitioner might discover an enlarged thyroid or a nodule by simple palpation of your neck. If your doctor suspects that you might have a thyroid disorder, they might refer you to an endocrinologist for further investigation. Some of the tests that may be ordered by your doctor include:

• Thyroid Stimulating Hormone (TSH): It’s usually the first test ordered by your doctor to assess whether your thyroid gland is working more or less than normal.
• T3 and T3 levels: These usually complement TSH and allow your doctor to confirm that the problem is in the thyroid gland itself.
• Antibody tests: If your doctor suspects that you might have Hashimoto’s thyroiditis or Grave’s disease based on your symptoms and other lab tests, they might order further workup to confirm.
• Ultrasound imaging: Your doctor might order an ultrasound to see how the thyroid looks and assess the possibility of malignancy.
• Thyroid scan: This is an imaging technique that uses radioactive isotopes to assess how the different regions of your thyroid gland are functioning.
• Biopsy: Also called FNA (fine needle aspiration) is when a small piece is taken from your gland and sent to the lab to investigate its nature and rule out malignancy.

Having a goiter can be a merely cosmetic problem; however, it usually signifies thyroid hormonal disturbances that require medical assessment. Goiters can develop with a number of disorders, and these can be hyperthyroid or hypothyroid in nature. Regardless of the cause, a wide variety of treatment options are available, these include prescription drugs, radioactive iodine ablation, and thyroid surgery (thyroidectomy).

Depending on the medical condition causing your goiter, and your symptoms, your endocrinologist would provide you with a specific treatment plan suited for your case.

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Sources:

• https://www.hormone.org/diseases-and-conditions/goiter
•  http://www.thyroid.org/what-is-a-goiter/
• http://www.thyroid.org/iodine-deficiency/
• https://www.mja.com.au/journal/2016/205/4/managing-thyroid-disease-general-practice

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