Science online

Types of Goiter, Symptoms and Causes of thyroid swelling, Is goiter dangerous

by ·

Goiter is an enlarged thyroid gland irrespective of the cause or function. Normally, the gland is 20-25 g in weight and is neither visible nor palpable. However, the Isthmuss sometimes apparent, particularly during swallowing & can be felt in very thin persons.

Features of a Thyroid Swelling

  1. Anatomical site: Lower anterior part of the neck, deep to the sternomastoid muscle.
  2. Shape: Butterfly; however, enlargement may be unilateral or asymmetrical.
  3. Mobility with deglutition: A goiter moves up and down with deglutition.

Types of Goiter

  1. Simple Goiter.
  2. Toxic Goiter.
  3. Special Goiter.

Nodules may be seen as single lesions (uninodular), or several nodules may coalesce & remain segregated in one lobe of the thyroid gland (plurinodular), or several nodules of different sizes may be scattered irregularly throughout the thyroid gland (multinodular).

Goiter and nodules

Goiter and nodules

History taking

Personal History (Personal Data)

Age

  • Young Age……………..Physiological goiter, papillary carcinoma.
  • Between 25-40 у………….SNGL – 1ry thyrotoxicosis.
  • Between 30-45 y……….2ry thyrotoxicosis.
  • Elderly………….. Cancer of the thyroid.

Gender

  • Generally, females are more commonly affected by goiter than males.
  • Males are more affected by retro-sternal goiter.
  • Males with a solitary thyroid nodule are more affected with thyroid cancer than females.

Symptoms (Complaints)

Symptoms due to thyroid swelling:

  1. A lump in the neck which is usually discovered accidentally & is slow-growing, causing disfigurement. Sudden appearance or rapid increase in size may be due to hemorrhage in a cyst or necrotic nodule, rapidly growing carcinoma, or subacute thyroiditis.
  2. Pain due to the same causes of rapid enlargement.

Pressure symptoms: On 2 tubes (esophagus/trachea), 2 nerves (RLN/sympathetic trunk) & 2 vessels (carotid artery/IJV):

  • Dysphagia: Because the thyroid has to be pulled upward during swallowing.
  • Dyspnea: due to pressure over the trachea, especially if retro-sternal or malignant.
  • Hoarseness of voice, due to recurrent laryngeal nerve (RLN) affection in Cancer. Horner’s syndrome due to affection of the cervical sympathetic trunk in cancer thyroid.
  • The carotid artery causes dizziness & fainting attacks (rare).
  • IJV causing congestion of the face.

Endocrine symptoms

  1. Eye symptoms: Staring look, difficulty in closing the eye due to proptosis, or even diplopia in advanced cases of thyrotoxicosis.
  2. Symptoms of toxicity: Dyspnea on effort, tiredness, palpitation, intolerance to hot weather, decreased weight despite increased appetite, diarrhea, nervousness, irritability, and menstrual disturbances.
  3. Symptoms of hypothyroidism (myxedema): increase in weight, Puffy eyelids with waxy yellow complexion, intolerance to cold weather, slow thought & speech, apathy, easy fatigability, loss of hair & constipation.

Present History

Onset

  • The lump is usually accidentally discovered (ask about stress).
  • The onset of toxic symptoms in relation to the onset of the lump is important. In 1ry thyrotoxicosis, both appear simultaneously. In 2ry thryotoxicosis, the lump appears first. Subacute thyroiditis has an acute onset.

Progress

  • Slowly progressing………….. Simple & toxic goiters.
  • Rapidly progressing…………. Cancer thyroid, especially the anaplastic type.
  • Self-limiting (within 1-3 m)………… Subacute thyroiditis.
  • Sudden. increase in size (+/-pain)………. Suggests hemorrhage) in a cyst infection of cancer.
  • Ask about a change in mobility……….. Restricted (eg. cancer).
  • Change in consistency……….. Harder (malignant transformation or calcification).

Course of treatment

You should determine the following:

  • Type of drugs received by the patient (e.g., Lugol’s 12, Carbimazole, etc).
  • The duration of R/.
  • Effect of R/ on the swelling or condition of the patient.

Past History

  • Similar condition: SNG may turn 2ry toxic or malignant.
  • Intake of goitrogens e.g. drugs (Thiocyanates for hypertension) or food (cabbage).
  • Previous irradiation of the neck or the scalp may predispose to thyroid cancer.
  • Previous thyroid operation. Recurrence or fixation (limited mobility).

Family History

  • Family history of thyroid disease is important in endemic goiter, Hashimoto’s disease (autoimmune), medullary carcinoma of the thyroid & dyshormogenesis.
  • Goiter deafness in Pendred’s disease = hereditary goiter.

Special Habits

Diet e.g. colloidal goiter: Some vegetables contain chemicals which are goitrogens i.e. they interfere with hormone synthesis. An excess of cabbage in the diet can cause goiter.

General Examination

General Condition

  • Is the patient thin or fat?………….. Wasting? Myxedema?
  • Evidence of hyperfunction ?………. Staring, excitable, trembling, nervous, and sweating?
  • Evidence of hypofunction?……….. Slow thinking, dullness, apathy, puffy eyelids, etc?

Vital Signs

  • HR & rhythm: Tachycardia (which persists during sleep to exclude neurosis) suggests thyrotoxicosis (<90/min = mild, 90-110/min = moderate > 110/min = severe toxicity). Extra-systoles, atrial flutter or fibrillation may occur in severe thyrotoxicosis.
  • Temperature: May be slightly elevated in thyrotoxicosis.
  • Blood pressure: There may be systolic hypertension & ↑ pulse pressure in thyrotoxicosis.
  • Respiratory rate: Dyspnea at rest in toxic heart failure or in retro-sternal goiter.

Head & Neck

  • Skull: For hard masses (metastases) in late cancer goiter.
  • Scalp & face: Malar flush & scanty dry head hair (myxedema).
  • Tongue:
  1. Tremors of protruded tongue (1ry toxic goiter).
  2. Cyanosis (toxic heart failure).
  3. Ectopic lingual thyroid(a tongue lump).

Neck

  1. Congested neck veins in thyrotoxic heart failure (pulsating) & in retro-sternal goiter (non-pulsating).
  2. Cervical lymphadenopathy: hard in malignant goiter.
  3. Position of trachea (By feeling with the finger-tip in the supra-sternal notch).

The Eyes

Look for Horner’s syndrome (ptosis, myosis, enophthalmos), in cancer thyroid with infiltration of the cervical sympathetic trunk.

Look for signs of toxicity:

  • Lid retraction (Dalrymple’s sign): The upper eyelid is higher than normal, but there is no exophthalmos.
  • Stellwag’s sign: Staring look due to infrequent blinking.
  • Lid lag (Von Graefe’s sign): The patient is asked to follow the finger moved up and down.
  • The upper lid does not keep pace with the moving eyeball.
  • Lack of convergence (Moebius sign): The patient is asked to follow the finger while approaching the root of the nose. There is difficulty in convergence when the finger comes near the eye.
  • Joffroy’s sign: The patient can look upwards without wrinkling of the forehead due to weak forehead muscles (frontalis).

Exophthalmos: The sclera becomes visible all around the iris. Naffziger’s Method: Stand behind the seated patient & tilt his head backwards, holding in a manner that keeps the hair out of the way. Observe the eyeballs; your plane of vision being that of the super-ciliary ridges. If no proptosis is noticed, then the staring look of the patient is due to lid retraction & not due to true exophthalmos.

Chemosis, Ophthalmoplegia, and dilated, congested conjunctival blood vessels, in severe cases of thyrotoxicosis. Always note the relations of the iris to the sclera for proper differentiation between lid retraction & exophthalmos. Tremors of the eyelids in semi-closed eyes.

The Heart

Examine the heart for signs of heart failure (in 2ry toxicosis).

The Chest

  • Dullness over the manubrium (percussion) …………. Retro-sternal goiter.
  • Basal dullness rising towards the axilla (percussion)………… (Pleural effusion (lung metastases).
  • Rhonchi & Crepitations (auscultation)…………… Lung metastases in thyroid cancer.
  • Basal Crepitations (auscultation)………………………. Heart failure (2ry thyrotoxicsis).

The Abdomen

Hepatomegaly e.g., in late malignant goiter (hard & irregular).

Nervous System

Bilateral exaggerated reflexes (ankles & knees) in thyrotoxicosis.

The Hands

  • Moist & warm in thyrotoxicosis.
  • Fine tremor in thyrotoxicosis: Ask the patient to hold her arms out in front of her, elbows & wrists straight, fingers straight & separated.

Lower Limbs

  • Edema (heart failure)/or peri-tibial myxedema, which is slightly pitting with orange chins at the beginning, but becomes non-pitting later on, with deep purple chins
  • Tender masses in long bones (metastases in late-stage thyroid cancer).

Local Examination

The patient is examined while sitting in a chair. The doctor stands in front of her during inspection, then behind during palpation.

Inspection

Look at the neck for the presence of swelling & note the number, site, size, extent, shape, color, skin overlying the swelling, pulsations & any pressure effects.

In obese & bull-necked individuals, inspection of the thyroid is made easier, by the patient throwing her head backwards, and pressing her occiput against her clasped hands (Pizzillo).

Look for dilated veins (thyrotoxicosis, malignancy & retro-sternal goiter), or pulsations (thyrotoxicosis), face congestion & cyanosis (retrosternal goiter).

Does the swelling move with deglutition?

Ask the patient to swallow. A thyroid swelling moves upward with deglutition, but may be limited by malignancy, inflammation, irradiation, scar of previous operation, or retro-sternal extension.

Does it move upwards with the protrusion of the tongue?

Ask the patient to open her mouth & protrude her tongue. A thyroglossal cyst does.

Palpation

Check the position of the trachea from the front. Comment on the Swelling: Stand behind the patient, your thumbs on the scalp, tilting the head forwards. Palpate with the other four fingers of each hand. A normal thyroid is not palpable. If palpable, comment on: Is the whole thyroid enlarged?, Is there one nodule or more? Smooth enlargement of one lobe of

  • Comment on local temperature & tenderness, confirm information obtained by inspection (site, size, etc), surface, edge, consistency, thrill & mobility (horizontally, vertically).
  • Confirm mobility with deglutition.
  • Try to get below the swelling. Is there an extension into the mediastinum
  • (retro-sternal)?
  • Pulsations of both carotids are felt and compared.
  • Cervical L.Ns are palpated.
  • Berry’s Sign

When the gland enlarges, it displaces the carotid tree backwards & outwards; therefore, in many cases, the pulsation of the carotid artery can be felt behind the posterior edge of the swelling. In malignancy, the artery tends to become surrounded by the tumor.

Percussion

Percuss over the sternum for retro-sternal extension (dull). This is confirmed by plain X-ray & CT-scan, The thyroid nature of the dullness is confirmed by thyroid scanning.

Auscultation

Auscultation over a thyrotoxic goiter may reveal a bruit.

Criteria of Malignant Transformation

Glandular Criteria

  1. Rapid growth
  2. Fixation
  3. Consistency (hard)ز
  4. Edge (ill-defined).
  5. Onset of pain.

Extra-glandular Criteria

  1. Pressure (more evident).
  2. VC paralysis (RLN).
  3. Horner’s syndrome.
  4. Cervical LNs.
  5. Unequal carotid pulsations.
  6. Distant metastasis.

Investigations

  1. Routine laboratory tests.
  2. Thyroid Function Tests (T3, T4, TSH), are done in doubtful cases & interpreted in light of clinical findings.
  3. Thyroid antibodies (anti-TPO, anti-Tg) & serum calcitonin in selected cases.
  4. Plain X-Ray of the neck & upper chest: Soft tissue shadow (retrosternal goiter-RSG).
  5. CT scan for RSG, anatomical relations & cervical LNs.
  6. US can diagnose: Cystic from solid nodules, detect clinically impalpable nodules, identify suspicious nodules & güide FNAC for more accurate diagnosis.
  7. Thyroid scanning is useful in case of a solitary thyroid nodule (STN) (It can show a cold or hot nodule).
  8. Indirect Laryngoscopy (for assessment of the vocal cords).
  9. Biopsy (FNAC or Tru-gut needle biopsy) in case of suspected malignancy.

Diagnosis and differential diagnosis

Is it a goiter or not?

A thyroid swelling has the following characteristics:

  1. Anatomical Site: Lower anterior part of the neck, deep to the sternomastoid muscle.
  2. Shape: Butterfly (2 lobes + isthmus), however, it may be unilateral or asymmetrical.
  3. Mobility with deglutition: A goiter moves up & down with deglutition. However, mobility may be restricted in certain cases (refer back). Also, remember that not every swelling mobile with deglutition is a goiter. Some other swellings do.

Swellings that move with deglutition

  • Goiter (thyroid gland).
  • Thyroglossal cyst.
  • Median ectopic thyroid tissue.
  • Parathyroid swellings if ever palpable,
  • Pre-laryngeal (Delphian) LN. & pre-tracheal LNs.
  • Subhyoid bursa
  • Adam’s apple bursitis.
  • Laryngocele.
  • Laryngeal cold abscess.
  • Pharyngeal diverticulum.

Which type of goiter? simple-toxic-malignant ?

Demonstrating, after examination, that the swelling is an enlarged thyroid, you should be able to conclude the following information about the gland.

  • Type of goiter: This is reached by determining the state of activity of the gland, and its local condition (diffuse, nodular or one nodule).
  • The state of activity of the gland is determined, whether normal (simple goiter), hyperthyroid (toxic goiter, 1ry or 2ry), or hypothyroid (myxedema). This is usually reached through history & general examination.
  • Is goiter malignant? Malignancy could be suspected from the rapid rate of growth, presence of pain, hoarseness of voice, pressure symptoms, absent or weak carotid pulsation & enlarged cervical L.Ns.
  • Is the swelling obstructing the trachea, causing stridor? (rare, but vital).
  • Does the swelling extend behind the sternum?

Retro-sternal extension

Criteria Include:

History: Postural dyspnea, stridor, cough, wheezing, choking, dysphagia, etc.

Examination:

  • Dilated veins in front of the neck and sternum.
  • Enlarged thyroid with non-visible lower border on swallowing (inspection).
  • Impalpable lower border on palpation.
  • Dullness on percussion over the manubrium sterni.
  • Flushing of the skin & dilatation of the EJV during raising the arms or hyperextension of the neck ( = Positive Pemberton’ Sign).

Investigations

Final Diagnosis?

After determining whether it is simple, toxic or malignant, the local condition of the gland is assessed:

  • Is it diffusely enlarged (physiologic, colloid, 1ry thyrotoxicosis, or thyroiditis)?
  • Is it diffusely nodular (Simple nodular, 2ry  thyrotoxicosis)?
  • Is it one nodule which is felt (Solitary adenoma, cyst, toxic nodule, or malignant nodule)?
  • Malignant goiter is hand, may be fixed, and there may be cervical LN metastases.

Causes of HARD/thyroid swelling?

  1. Thyroid cancer.
  2. Calcified SNG.
  3. Tuberculona-Gumina
  4. Hashimoto’s disease.
  5. Riedel’s disease.
  6. Cancer larynx invading the thyroid gland.

Causes of HOARSENESS of voice in a thyroid case?

  1. Compression of RLIN by a huge goiter or RSG.
  2. Infiltration of the RLN by thyroid carcinoma (more common).
  3. Post-operative due to surgical injury of the RLN.
  4. Myxedematous infiltration of the REN due to large doses of ATD.

Causes of DYSPNEA in a thyroid case?

Non-operative Causes:

  1. SNG single nodular goiter (RSG, huge size, hemorrhage in a nodule) by: Displacement of trachea (unilateral goiter), Compression of the trachea from both sides, and Softening of the trachea (tracheomalacia).
  2. Toxic goiter (thyrocardiac patient, exertional due to an increase in oxygen consumption.
  3. Malignant goiter (tracheal compression, RLN infiltration, lung 2).
  4. In all goiters (a psychöğenic element may play a role).

Operative Causes

  1. Laryngeal edema.
  2. Tracheal collapse
  3. Blood clot or hematoma.
  4. Foreign body.
  5. RLN involvement.

Causes of Occult Carcinoma?

  1. Naso-pharynx (Fossa of Rosenmuller).
  2. Posterior oro-pharynx.
  3. Hypo-pharynx.
  4. Pyriform Fossa of the larynx.
  5. Maxillary sinus & para-nasal sinuses.
  6. Papillary carcinoma of the thyroid (PTC).
  7. Salivary gland tumors (+).

You can subscribe to Science Online on YouTube from this link: Science Online

Histological structure of thyroid gland and Functions of Thyroid Hormones (T3 and T4)

Thyroid gland function, hormones, function, anatomy and Congenital anomalies

Posterior pituitary gland hormones & function, Control of ADH and Oxytocin hormone

Anterior pituitary gland function, hormones, location and Effects of Growth Hormone

Pituitary gland function, structure, location, hormones and anatomy

Endocrine system structure, function, disorders, Endocrine Glands and Hormones types

Tags:

You may also like...