A goiter is the abnormal enlargement of the thyroid gland. Just because the thyroid is enlarged, does not mean that it is not working properly. Goiter is seen in patients producing too much thyroid hormone, too little, or the correct amount.
The most common cause of goiter worldwide is iodine deficiency. It is no longer a common cause of goiter in the U.S. as iodized salt is now used. The main goal of the thyroid is to make thyroid hormone, which it does by concentrating iodine from the blood. Without iodine, there will be no thyroid hormone. Without thyroid hormone, the pituitary gland will send thyroid stimulating hormone to the thyroid. This overproduction of thyroid stimulating hormone acting on the thyroid will cause the thyroid to grow in size, producing a goiter.
More common causes of goiter in the U.S. are Hashimoto’s thyroiditis, Graves’ disease, and multinodular goiters. In Hashimoto’s thyroiditis, the thyroid is attacked by the patient’s own immune system and begins to lose function and produce less hormone. As in iodine deficiency, the pituitary detects this low thyroid hormone and produces thyroid stimulating hormone. This stimulation of the thyroid to grow, produces a goiter.
Multinodular goiter is a disorder in which one or more nodules grow inside the thyroid gland causing thyroid enlargement. Patients can present with a single large nodule or multiple smaller nodules. Therefore, in the early stages of this disorder with small nodules, the overall thyroid size may not be enlarged yet. The exact mechanism of how goiter is formed in this disorder is not well known.
The most common sign of goiter is a swelling in the front of the neck, which often brings patients to their primary care providers. Not all goiters are seen by the naked eye and are felt by the patient or on examination by the medical provider. Most goiters are painless, but as they grow in size, they can cause a cough and make it difficult to swallow or breathe as the thyroid presses on structures behind it, including the trachea and esophagus.
Once a medical provider is suspicious of goiter based on physical exam, some tests are needed to be done to figure out the underlying cause of the goiter in order to provide the best treatment. The first one will likely be thyroid function tests. Thyroid function tests will measure the amount of hormone produced by the pituitary and thyroid, which can clue you in on what may be the cause of your goiter. If your thyroid function tests come back underactive, you may have Hashimoto’s thyroiditis or iodine deficiency.
If a nodule is detected, a fine needle aspiration with biopsy will usually be ordered as it is the best initial test to evaluate a nodule. Ninety percent of thyroid nodules are benign, with the most common being a follicular adenoma. Your provider may also decide to order a thyroid ultrasound to evaluate any nodules present. An ultrasound can be done to show if a nodule is cystic or solid, and to monitor a nodule on a periodic basis to see if it is growing or shrinking.
Treatment for goiter depends on the size, your signs and symptoms, and the underlying cause. We will focus on the four main causes as discussed above. If you are suffering from iodine deficiency, you will be given iodine supplementation which should reduce the size of the goiter. However, it may not completely return to its normal size.
If the cause of your goiter is Hashimoto’s thyroiditis, you will be prescribed thyroid hormone supplementation.
Most patients with multinodular goiter have normal levels of thyroid hormone. These goiters do not require any treatment. They can be observed on a twice-yearly basis to see if the nodules are increasing in size. If the nodules are large and/or are causing symptoms, surgical removal can be performed.
If you suspect you have a goiter, you should be sure to get checked out by a doctor.
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