THYROID GOITER
THYROID GOITER
- Goiter means the thyroid has grown to a large size. Thyroid goiters are usually made up of multiple thyroid nodules
- Majority of goiters are benign (non-cancerous) and most of the problems that goiters cause are due to their increased size
- A large thyroid goiter can push on the other structures in the neck causing compressive symptoms
Goiter is a condition where there is an abnormal enlargement of the thyroid gland. Most goiters are painless, but they may produce symptoms due to their increased size
Larger goiters most commonly produce symptoms of:
- A swelling or mass in the neck
- Irritating cough followed by a sensation of choking
- A feeling like you need to swallow something or like something is stuck in the throat
- Difficulty in swallowing
- Voice change
Excess production of the thyroid hormones, which include:
- Unexplained weight loss
- Heat intolerance
- Tremor, Nervousness
- Rapid or irregular heart rate
Reduced production of the thyroid hormones, which include:
- Excess weight gain
- Increased sensitivity to cold
- Muscle weakness
- Puffy face, Constipation
- Iodine deficiency
- Overgrowth of normal thyroid tissue
- Thyroid cysts
- Inflammatory diseases of the thyroid (thyroiditis)
- Grave’s disease
- Multinodular goiter
- Thyroid Cancer
Evaluation of a thyroid goiter Patient includes:
- Complete medical history and physical examination
- High resolution ultrasonography of the neck (thyroid and lymph nodes)
- Thyroid profile : TSH, T3 and T4
- Fine needle aspiration cytology of suspicious nodule
Presence of goiter with elevated thyroid hormone levels is the only instance that a radioiodine scan is indicated
When physical examination and ultrasonography cannot completely determine the entire extent of goiter, then a CT scan is ordered. The CT scan will show areas that the thyroid goiter extends and help thyroid surgeon in preoperative planning regarding safe and effective approach to remove the entire goiter gland and spare all other structures
1. Observation
- If the ultrasound and FNAC suggests that the patient has benign small goiter with no symptoms, then the goiter may be observed
- Physical examination, thyroid blood tests and ultrasound should be repeated every six months. If the thyroid goiter increases in size or develops symptoms, surgery may be needed
2. Thyroid Hormone Therapy
- Thyroid hormones are prescribed in patients with hypothyroidism
- Antithyroid medication are prescribed in patients with hyperthyroidism
3. Surgery
Thyroid surgery is advised in patients with:
- Large goiter (producing a visible mass in the neck)
- Goiters producing pressure symptoms on the breathing tube or swallowing tube
- Goiters associated with excessive thyroid hormone production
- Thyroid nodules with FNAC reports indicative of Indeterminate nodules or suspicious for cancer
- Multinodular goiters producing symptoms
THYROID NODULE
- A thyroid nodule is a lump in the thyroid gland in the neck
- Thyroid cancer is the biggest concern when nodules form, but fortunately the chance of it happening is low. More than 90-95% of all thyroid nodules are benign (non-cancerous)
- Nodules are more common in women than in men
- Most nodules are asymptomatic. When large, thyroid nodules may cause a sense of pressure in the neck and may rarely affect breathing and swallowing
- Patients with a thyroid nodule should consult a thyroid specialist who can assess and help determine what treatment is needed. Usually, a fine needle aspiration(FNA) biopsy is necessary to determine if a thyroid nodule is benign or malignant
QUICK FACTS
- Thyroid nodules are three times more common in women than in men
- 30% of 30-year-old women will have a thyroid nodule
- The incidence of thyroid nodules increases with age, most women will develop a thyroid nodule by the time they are 50 years old
- Thyroid cancer is the biggest concern when nodules form, but fortunately the chance of it happening is low. Less than 5 percent of all nodules are cancerous
- More than 95% of all thyroid nodules are benign (non-cancerous)
- Some thyroid nodules are actually cysts, which are filled with fluid rather than thyroid tissue
Most thyroid nodules usually do not cause symptoms, however when they do cause symptoms they are most commonly:
- A lump/swelling in the neck (thyroid)
- A feeling of fullness, pain or pressure in the throat
- Uncomfortable pressure sensation on the breathing tube
- A sense of feeling like they need to swallow something or difficulty swallowing
- Discomfort in the neck
- Frequent coughing during the day and a need to keep clearing the throat
Thyroid nodules may sometimes produce the thyroid hormone, thyroxine, in excess, resulting in symptoms of hyperthyroidism which include:
- Unexplained weight loss
- Heat intolerance
- Tremor
- Nervousness
- Rapid or irregular heart rate
Thyroid nodules may also be associated with low thyroid hormone levels, resulting in symptoms of hypothyroidism which include:
- Fatigue (feeling tired)
- Frequent, heavy menstrual periods
- Weight gain, Forgetfulness
- Dry, coarse skin and hair, and hair loss
- Trouble dealing with cold temperatures
The exact cause is not known. Several conditions may cause or predispose to the development of thyroid nodules including:
–Iodine deficiency
–Overgrowth of normal thyroid tissue
–Thyroid cysts
–Inflammatory diseases of the thyroid (Thyroiditis)
–Multinodular goiter
-Thyroid Cancer: Although the likelihood that a thyroid nodule is a cancer is quite low, the following are associated with an increased malignant risk:
- Age less than 30 years of age
- Age greater than 50 years of age
- Men greater than women
- A positive family history of thyroid cancer
- A positive family history of other endocrine cancers
- A history of radiation exposure
- Recent onset thyroid nodules
- Larger thyroid nodules
- Vocal cord paralysis (hoarseness)
Risk factors for developing thyroid nodules include:
- Family history of thyroid nodules or thyroid cancer
- Increasing age
- Women are more at risk than men
- History of radiation exposure to the head and neck region
The exact cause of most thyroid nodules is not known, so most likely, its not possible to prevent them. Make sure to eat food that contains iodine (table salt, dairy products, seafood, meat, etc.) which can prevent one cause of thyroid nodules
It is important to see a thyroid specialist when you think you may have a thyroid nodule or goiter, or if you are experiencing abnormal swelling or pressure in your neck, especially difficulty in breathing or swallowing and also if you experience any of the symptoms of hypothyroidism or hyperthyroidism
Most thyroid nodules are benign (non-cancerous), but a small percentage of thyroid nodules are malignant (cancer). Those thyroid nodules that are cancer, tend to be very slow growing. Thoughtful evaluation and consultation by a Thyroid specialist is required for thyroid nodules. You will be advised High resolution ultrasonography of the neck and fine needle aspiration cytology (FNAC) to rule out cancer in the nodule
After a complete medical history and physical examination, the following tests are required for further evaluation of the nodule:
- Thyroid hormone level test
- Thyroid ultrasound: This test uses sound waves to determine the exact size and if a nodule is solid or a fluid-filled cyst
- Fine-needle aspiration cytology (FNAC): A very thin needle is used to take a sample of cells from one or more thyroid nodules to assess their exact nature
Only in patients in whom hyperthyroidism is present in addition to the presence of the thyroid nodule, a radioiodine scan (thyroid scan) is indicated
Treatment options include:
- Watchful waiting –
- Patients with small benign nodules without symptoms may choose watchful waiting
- Periodic physical examination and ultrasonography every six monthly to monitor the growth of the nodule are advised
- If the thyroid nodule increases in size or develops symptoms or develop suspicious features, surgery is advised
- Surgery – Sometimes clearly benign thyroid nodules are managed with surgery. Some potential indications for removing benign thyroid nodules include:
- Thyroid nodules which are large (producing a visible mass in the neck)
- Nodules producing symptoms on the breathing tube or swallowing tube
- Nodules producing excessive thyroid hormone
- Nodules exhibiting continues growth
- Thyroid nodules leading to anxiety
- Multinodular goiters producing symptoms
- Nodules with suspicious features like voice change, recent onset nodules
Nodules that are suspicious on biopsy are usually treated with surgery. Treatment for most cancerous thyroid nodules begins with surgery. The most common thyroid cancers are papillary thyroid carcinoma, follicular thyroid carcinoma and Hurthle cell carcinoma
Most thyroid nodules would be diagnosed as benign or malignant (cancer) on FNAC. However, 20-25% of FNA biopsies are considered indeterminate. This implies that we cannot definitely decide whether the nodule is benign or malignant based on that biopsy alone. Alternatives for indeterminate biopsy include:
- Repeat biopsy
- Repeat biopsy with special tests to analyze the genetic make-up of the tumor
- Considering surgery for a definitive answer
THYROID CYSTS
- Thyroid cysts are enlarged fluid-filled regions of the thyroid that may be small (less than 1 cm) or quite large and sometimes arise very suddenly
- Cystic nodules can remain stable, occasionally get smaller and sometime continue to expand
- Thyroid nodules which are entirely cystic, are usually benign whereas thyroid cysts which contain both solid and fluid components have higher risk of cancer
Thyroid cysts are usually asymptomatic. Some cysts may rapidly expand due to bleeding within the cyst. Rapidly expanding cysts can become symptomatic producing a noticeable lump in the neck, pain, difficulty swallowing and very rarely change in voice
Thyroid cysts that are completely fluid filled have a much lower risk of thyroid cancer compared to cysts that have solid components. Cysts should be assessed by a thyroid specialist and evaluated by high resolution ultrasonography and ultrasound guided fine needle aspiration cytology
- Simple thyroid cysts which are 3cm or less in size can be observed and monitored for changes
- Aspiration and instillation of ethanol may be advised in simple cyst. Aspiration of thyroid cysts alone is largely ineffective and results in rapid return of the cyst fluid
- Thyroid surgery is recommended in multiple large thyroid cysts, complex cysts and when FNAC is suspicious
