goiter%20nontoxic%20(simple)--%20diffuse%20-and-%20multinodular
GOITER NONTOXIC (SIMPLE): DIFFUSE & MULTINODULAR
Nontoxic goiter is thyroid enlargement unrelated to hypothyroidism, hyperthyroidism, inflammation or neoplasia.
Etiology is usually unknown. Some known causes include iodine deficiency, iodine excess, goitrogen ingestion, autoimmune disorders, thyroid hormone production defects and certain medications.
It is usually asymptomatic.
Symptomatic patient may present with painless neck swelling, cosmetic complaints, shortness of breath, sudden increase in goiter size with pain due to hemorrhage, larger goiter causing obstructive signs eg dysphagia, choking sensation and Pemberton's sign.

Diagnosis

  • Diagnosis of exclusion to rule out goiter due to hypothyroidism, hyperthyroidism, autoimmune thyroiditis, invasive fibrous thyroiditis, medications & iodine deficiency or excess

History

  • Cosmetic complaints (disfigurement due to enlarged goiter), obstructive complaints, growth rate & family history

Physical Examination

  • Inspect neck (check size, nodules & texture of goiter), detect obstructive signs (stridor, Pemberton’s sign, plethora, etc)
    • Nontoxic multinodular goiter: Multiple, distorted nodules of varying sizes
    • Diffuse nontoxic goiter: Symmetrical, enlarged, non-tender, soft gland w/o nodules 
  • A retrosternal goiter may not be evident on physical exam

Laboratory Tests

Thyroid Function Tests

  • Measure serum thyroid stimulating hormone (TSH) & free thyroxine (FT4) levels [measure serum free triiodothyronine (FT3) levels if FT4 is normal & in nodular goiter] to exclude hyperthyroidism & hypothyroidism
    • Euthyroid state (normalized serum FT3 & FT4 levels) may suggest diagnosis of goiter (simple/nontoxic)
    • TSH suppression may develop due to increasing goiter size
    • FT3 toxicosis may occur in multinodular goiter
  • Measure: Thyroid peroxidase (TPO) antibodies, thyroglobulin antibodies & TSH receptors antibodies to exclude autoimmune thyroid diseases

Fine Needle Aspiration Cytology (FNAC)

  • Performed to rule out malignancy in cases of suspicious nodules
  • May be performed guided w/ ultrasound in cases of nonpalpable nodules w/ diameter of ≥1 cm

Pulmonary Function Tests

  • Performed to determine the degree of airway obstruction

Imaging

Thyroid Ultrasound

  • Measures thyroid size, identifies the structure & evaluates diffuse changes in the thyroid gland
  • Provides a measure of goiter growth rate over time & posttreatment
  • Determines extent of nodularity

Thyroid Scintigraphy

  • Visualizes goiter, determines its inherent properties; identifies hot & cold nodules

X-ray of the Neck & Upper Mediastinum

  • Used to determine the presence of tracheal compression

Computed Tomography (CT)/Magnetic Resonance Imaging (MRI)

  • Perform CT/MRI (to evaluate the anatomy of the goiter & the extent of substernal extension), if substernal goiters are suspected
  • Pemberton’s sign, obstructive signs & symptoms suggest substernal goiter
  • Substernal goiter may obstruct thoracic inlet & compress trachea

Complications

  • Potential complications: Recurrent laryngeal nerve palsy (1-2%), hypothyroidism (5-8%) & hypoparathyroidism (2-4%)
  • May administer low dose of T4 after surgery to suppress regrowth of goiter if serum TSH is elevated
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