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The Simple Guide to Goiter

By: Marc Evans Abat, MD, FPCP, FPCGMThe Simple Guide to Goiter

Got a bump in front of your neck?  Most likely this is a goiter unless you’re a man with a rather prominent Adam’s apple.   In the Philippine Thyroid Diseases Study (PhilTiDeS 1) in 2012, 8.9% of those surveyed and examined had goiters.  That is 1 out of 11 persons surveyed having the condition. 

A goiter is an enlarged thyroid gland. What is this thyroid gland and what is its role in the body?  The thyroid is one of our endocrine glands, secreting hormones directly into the bloodstream.  This gland is shaped like a butterfly and is located just below the voice box or Adam’s apple and in front and around the sides of the trachea.  It secretes the following important hormones:

  • Thyroxine (T4) and triiodothyronine (T3) – Both serve to regulate body metabolism and function, including how fast we consume energy from fats and carbohydrates, how protein is metabolized, and how it controls our basic vital functions like temperature modulation and heart rate.
  • Calcitonin – An important hormone involved in the regulation of calcium levels in the body.

The regulation of the functions of the thyroid gland is an intricate circuitry that involves the following:

  1. The hypothalamus serves to check the amounts of thyroid hormone in the body.  It will then control the amount of thyroid-stimulating hormone that the pituitary gland will secrete.
  1. The pituitary gland secretes a thyroid-stimulating hormone which directly stimulates the production of T4 and T3 from the thyroid.
  1. The amount of T4 and T3 in the blood serves as a negative feedback to the hypothalamus.  Too much thyroid hormones reduce the amount of stimulation on the thyroid gland and vice versa.

So why do the thyroids enlarge?  Because it wants to be famous – just kidding!

The thyroid enlarges due to the following causes:

  1. Iodine deficiency is a common cause in many parts of the world.  The thyroid compensates by increasing its size to obtain more iodine.  Iodine can be found mainly in seafood and soil near the coasts.  It is but logical that those who live in areas with poor access to seafood or food that is enriched with iodine can develop a goiter.  Others develop goiter from a diet rich in cruciferous vegetables (e.g. cabbage and broccoli), which has substances that inhibit iodine uptake and hence reduce thyroid hormone production.
  2. There are diseases that cause overproduction of the thyroid hormone, leading to enlargement of the gland due to the accumulation of these hormones.  Grave’s disease is one of these conditions, wherein antibodies or proteins (which are produced by the body’s own immune system) react to receptors in the thyroid gland, leading to overproduction and secretion of T4 and T3.
  1. There are diseases that cause the exact opposite effect, causing a poorly-functioning thyroid gland.  Hashimoto’s disease is also mediated by the body’s immune system, producing antibodies that lead to reduced thyroid function.  The thyroid becomes enlarged as a result of the growth effects of the excessive thyroid-stimulating hormone, which is the brain’s reaction to low levels of thyroid hormone.
  2. The thyroid can develop nodules either singularly or in multitude, leading to enlargement of one or both lobes of the thyroid.
  3. Thyroid cancer may manifest as enlargement of the thyroid, usually as a nodule.
  4. Pregnancy can cause enlargement of the thyroid with human chorionic gonadotrophin (HCG), a hormone that increases during pregnancy.
  5. Inflammation of the thyroid (thyroiditis), which may be due to an infection, may lead to swelling and thyroid pain.
  6. Aside from the above conditions, certain medications (e.g. amiodarone) or exposure to radiation on the neck can cause thyroid damage leading to a goiter.

How will someone with goiter feel?

It actually depends on many things:

  1. A normal thyroid is not usually visible and cannot be felt.  A goiter may start becoming visible to others or felt as a bump in the front of your neck.
  1. The size of the goiter may lead to mass effects like heaviness and discomfort in breathing or swallowing.
  1. Others may have some problems talking, possibly from compression or distortion of the voice box or impingement of the nerves to the vocal cords.
  1. Other symptoms depend on the underlying cause of the goiter:
  1. Accompanying excessive thyroid hormone production leads to weight loss, sweating, heat intolerance, increased appetite, agitation, bulging of the eyeballs, skin, and hair changes, fast heart rate, hyperdefecation, and eventually, complications on many organ systems including heart failure, delirium, and death.
  1. Low thyroid levels may lead to sluggishness, weight gain, cold intolerance, memory problems, weakness, lethargy, and skin changes.
  1. Cancer of the thyroid may prominently manifest with hoarseness and swallowing problems, plus other nodules around the neck or on other parts of the body.

How does one have his or her thyroid checked for a goiter?

It usually starts with having a doctor examine your neck for thyroid enlargement and other masses in the neck.  A goiter usually moves when one swallows.  The doctor may then order further examinations:

  • Thyroid hormones levels are checked, particularly thyroid-stimulating hormones.  They are usually the first hormones to be checked, then free T4 and free T3.
  • Immunologic tests are done depending on the levels of the thyroid tests to make sure the presence of stimulating or inhibiting antibodies.  Other proteins are also monitored in cases of thyroid cancer.
  • Ultrasound of the thyroid is usually done to verify the presence of a goiter or thyroid nodules and other neck abnormalities, like lymph nodes and thyroid blood supply or vascularity.
  • Thyroid scans are done to ascertain thyroid activity by injecting radioactive iodine then monitoring the level of iodine uptake.
  • Fine needle biopsy is done in certain situations, particularly for nodules with suspicious findings for cancer.

Treatment naturally depends on the underlying cause:

  1. Observation may be done for many nodules that are stable or do not have alarming features.
  1. Iodine supplementation may lead to some decrease in goiter size.
  1. Medications to suppress excess thyroid function in cases of an excessively functioning goiter may lead to some reduction in size.
  1. Supplementation with levothyroxine for those with a poorly-functioning thyroid gland may also help reduce the size of some goiters.
  1. Radioactive iodine therapy is offered as an option for permanent treatment of a hyperfunctioning goiter or thyroid cancer.  Radiation destroys the thyroid cells, however, this may leave the patient needing thyroid hormone supplementation after the thyroid is destroyed.
  1. Surgery may be an option for those with large goiters leading to compression of the neck.

Goiters can be managed properly with early recognition and diagnosis.  There is no need to carry that bump forever!

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