The term nontoxic goiter refers to enlargement of the thyroid which is not associated with overproduction of thyroid hormone or malignancy. The thyroid can become very large so that it can easily be seen as a mass in the neck. This picture depicts the outline of a normal size thyroid in black and the greatly enlarged goiter in pink. There are a number of factors which may cause the thyroid to become enlarged. A diet deficient in iodine can cause a goiter but this is rarely the cause because of the readily available iodine in our diets. A more common cause of goiter in America is an increase in thyroid stimulating hormone (TSH) in response to a defect in normal hormone synthesis within the thyroid gland. The thyroid stimulating hormone comes from the pituitary and causes the thyroid to enlarge. This enlargement usually takes many years to become manifest.
This picture depicts the typical appearance of a goiter in a middle aged woman. Note how her entire neck looks swollen because of the large thyroid. This mass will compress the trachea (windpipe) and esophagus (swallowing tube) leading to symptoms such as coughing, waking up from sleep feeling like you cant breath, and the sensation that food is getting stuck in the upper throat. Once a goiter gets this big, surgical removal is the only means to relieve the symptoms. Yes, sometimes they can get a lot bigger than this!
INDICATIONS FOR TREATMENT
Most small to moderate sized goiters can be treated by providing thyroid hormone in the form of a pill. By supplying thyroid hormone in this fashion, the pituitary will make less TSH which should result in stabilization in size of the gland. This technique often will not cause the size of the goiter to decrease but will usually keep it from growing any larger. Patients who do not respond to thyroid hormone therapy are often referred for surgery if it continues to grow.
A more common indication for surgical removal of an enlarged thyroid [goiter] is to remove those glands which are enlarged enough to cause compression on other structures in the neck such as the trachea and esophagus. These patients will typically complain of a cough, a slight change in voice, or nighttime choking episodes because of the way that the gland compresses the trachea while sleeping. This X-ray shows how an enlarged right lobe of the thyroid has moved the trachea to the patient’s left. The trachea (outlined in light yellow) should be straight from the mouth down to the lungs, but in this patient it is compressed and displaced far to the left. The enlarged gland can even compress the blood vessels of the neck which are also an indication for its removal. More about this on our page examining sub-sternal thyroids.
As always, suspicion of malignancy in an enlarged thyroid is an indication for removal of the thyroid. There is often a dominant nodule within a multinodular goiter which can cause concern for cancer. It should be remembered that the incidence of malignancy within a multinodular goiter is usually significantly less than 5%. If the nodule is cold on thyroid scanning, then it may be slightly higher than this. For the vast majority of patients, surgical removal of a goiter for fear of cancer is not warranted.
Another reason (although not a very common one) to remove a goiter is for cosmetic reasons. Often a goiter gets large enough that it can be seen as a mass in the neck. When other people begin to notice the mass, it is usually big enough to begin causing compression of other vital neck structures…but not always. Sometimes the large goiter causes no symptoms other than being a cosmetic problem. Realizing of course, if its big enough to be seen by your neighbors, something needs to be done…medications or surgery or it will most likely continue to get bigger.
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