WHAT IS THE THYROID GLAND?

The thyroid gland can be affected by exposure to radiation. The thyroid glands of children are especially sensitive to radiation, much more so than the thyroid gland of an adult.

SYMPTOMS
What is a goiter? The term goiter simply refers to the abnormal enlargement of the thyroid gland. It is important to know that the presence of a goiter does not necessarily mean that the thyroid gland is malfunctioning. A goiter can occur in a gland that is producing too much hormone (hyperthyroidism), too little hormone (hypothyroidism), or the correct amount of hormone (euthyroidism). A goiter indicates there is a condition present which is causing the thyroid to grow abnormally.

CAUSES
What causes a goiter? One of the most common causes of goiter formation worldwide is iodine deficiency. While this was a very frequent cause of goiter in the United States many years ago, it is no longer commonly observed. The primary activity of the thyroid gland is to concentrate iodine from the blood to make thyroid hormone. The gland cannot make enough thyroid hormone if it does not have enough iodine. Therefore, with iodine deficiency the individual will become hypothyroid. Consequently, the pituitary gland in the brain senses the thyroid hormone level is too low and sends a signal to the thyroid. This signal is called thyroid stimulating hormone (TSH). As the name implies, this hormone stimulates the thyroid to produce thyroid hormone and to grow in size. This abnormal growth in size produces what is termed a goiter. Thus, iodine deficiency is one cause of goiter development. Wherever iodine deficiency is common, goiter will be common. It remains a common cause of goiters in other parts of the world. Hashimotos thyroiditis is a more common cause of goiter formation in the US. This is an autoimmune condition in which there is destruction of the thyroid gland by ones own immune system. As the gland becomes more damaged, it is less able to make adequate supplies of thyroid hormone. The pituitary gland senses a low thyroid hormone level and secretes more TSH to stimulate the thyroid. This stimulation causes the thyroid to grow, which may produce a goiter. Another common cause of goiter is Graves disease. In this case, ones immune system produces a protein, called thyroid stimulating immunoglobulin (TSI). As with TSH, TSI stimulates the thyroid gland to enlarge producing a goiter. However, TSI also stimulates the thyroid to make too much thyroid hormone (causes hyperthyroidism). Since the pituitary senses too much thyroid hormone, it stops secreting TSH. In spite of this the thyroid gland continues to grow and make thyroid hormone. Therefore, Graves disease produces a goiter and hyperthyroidism. Multinodular goiters are another common cause of goiters. Individuals with this disorder have one or more nodules within the gland which cause thyroid enlargement. This is often detected as a nodular feeling gland on physical exam. Patients can present with a single large nodule or with multiple smaller nodules in the gland when first detected (see Thyroid Nodule brochure). Thus, in early stages of a multinodular goiter with many small nodules, the overall size of the thyroid may not be enlarged yet. Unlike the other goiters discussed, the cause of this type of goiter is not well understood.

In addition to the common causes of goiter, there are many other less common causes. Some of these are due to genetic defects, others are related to injury or infections in the thyroid, and some are due to tumors (both cancerous and benign tumors).

DIAGNOSIS
HOW DO YOU DIAGNOSE A GOITER? As mentioned earlier, the diagnosis of a goiter is usually made at the time of a physical examination when an enlargement of the thyroid is found. However, the presence of a goiter indicates there is an abnormality of the thyroid gland. Therefore, it is important to determine the cause of the goiter. As a first step, you will likely have thyroid function tests to determine if your thyroid is underactive or overactive (see Thyroid Function Tests brochure). Any subsequent tests performed will be dependent upon the results of the thyroid function tests. If the thyroid is diffusely enlarged and you are hyperthyroid, your doctor will likely proceed with tests to help diagnose Graves Disease (see Graves Disease brochure). If you are hypothyroid, you may have Hashimotos Thyroiditis (see Hypothyroidism brochure) and you may get additional blood tests to confirm this diagnosis. Other tests used to help diagnose the cause of the goiter may include a radioactive iodine scan, thyroid ultrasound, or a fine needle aspiration biopsy (see Thyroid Nodule brochure).

TREATMENT
How is a goiter treated? The treatment will depend upon the cause of the goiter. If the goiter was due to a deficiency of iodine in the diet (not common in the United States), you will be given iodine supplementation given in preparations to take by mouth. This will lead to a reduction in the size of the goiter, but often the goiter will not completely resolve. If the goiter is due to Hashimotos Thyroiditis, and you are hypothyroid, you will be given thyroid hormone supplement as a daily pill. This treatment will restore your thyroid hormone levels to normal, but does not usually make the goiter go completely away. While the goiter may get smaller, sometimes there is too much scar tissue in the gland to allow it to get much smaller. However, thyroid hormone treatment will usually prevent it from getting any larger. Although appropriate in some individuals, surgery is usually not routine treatment of thyroiditis. If the goiter is due to hyperthyroidism, the treatment will depend upon the cause of the hyperthyroidism (seeHyperthyroidism and Graves disease brochures). For some causes of hyperthyroidism, the treatment may lead to a disappearance of the goiter. For example, treatment of Graves disease with radioactive iodine usually leads to a decrease or disappearance of the goiter. Many goiters, such as the multinodular goiter, are associated with normal levels of thyroid hormone in the blood. These goiters usually do not require any specific treatment after the appropriate diagnosis is made. If no specific treatment is suggested, you may be warned that you are at risk for becoming hypothyroid or hyperthyroid in the future. However, if there are problems associated with the size of the thyroid per se, such as the goiter getting so large that it constricts the airway, your doctor may suggest that the goiter be treated by surgical removal. Whatever the cause, it is important to have regular (annual) monitoring when diagnosed with a goiter.

WHAT IS GOITER? It is the enlargement of the thyroid gland. The enlargement can be diffused or nodular. The goiter may also be toxic or non-toxic. Toxicity would refer to the presence or absence of symptoms such as palpitation, easy fatigability, weight loss or gain, or heat and cold intolerance.

WHAT ARE THE CAUSES? * Iodine deficiency people living in areas where Iodine is scarce (such as those living in the mountain) * Sex females are more likely to have thyroid problem than men * Pregnancy and menopause some pregnant patients are more likely to develop thyroid disease than those who are non-pregnant because of the hormone hCG. * Age the older you get, the higher the chances that you can get any thyroid problem * Family history of Thyroid diseases autoimmune diseases can be passed on from one generation to another, hence a history of thyroid disease in the family can increase a persons risk of developing a thyroid problem later on. * Medications there are certain medications that cause hormonal imbalance, which causes goiter (immunosuppressants, anti-retrovirals, amiodarone, and lithium) * Radiation any radiation exposure especially in the head and neck region increases the risk of developing any thyroid problem. * Cystic or solid mass if found in the anterior neck region, it can look like an enlarged thyroid gland. Inflammation an inflamed thyroid gland can increase its size.

PATHOPYSIOLOGY The thyroid gland is controlled mainly by the hypothalamus-pituitary-thyroid axis. The hypothalamus and pituitary gland are located in the brain, which secretes thyrotropin releasing hormone (TRH) and thyroid stimulating hormone (TSH) respectively. The hypothalamus releases TRH to stimulate the pituitary gland to secrete TSH. TSH then allows growth, cellular enlargement, thyroid hormone production and secretion of the thyroid gland. The thyroid gland on the other hand, sends back signals to the hypothalamus to either continue or stop producing TRH. Any disruption on the axis causes hormonal imbalance. This imbalance can then cause growth of the thyroid gland into an abnormal size. If not controlled, the thyroid gland can enlarge and cause obstruction of the airway and esophagus. Iodine is an important component of the synthesis and release of the thyroid hormones. If this is lacking, the production of thyroid hormone also decreases. The deficiency of the thyroid hormone sends signal to the TSH to produce more leading to hypercellularity and hyperplasia of the thyroid gland.

Signs and symptoms

- An enlarged anterior neck region - Difficulty swallowing - Difficulty breathing - Palpitations - Heat/cold intolerance - Fever

Diagnostics * Thyroid hormones TSH, FT3 and FT4 levels are determined if the goiter is due to increased or decreased levels of thyroid hormones. * Thyroid Ultrasound this tool used to determine the size of the thyroid gland and if the mass is cystic or solid; if the thyroid gland is diffusely enlarged or nodular. It is commonly used because it is non-invasive and economical. This tool can also be used as a guide in performing fine-needle biopsy. * CT Scan This is more accurate than ultrasound especially when the thyroid gland is diffusely enlarged. It can tell which structures adjacent to the thyroid gland are affected. * MRIThis has the same indication for CT scan * Thyroid scan this tool determines the function and anatomy of the thyroid gland. This is mostly used in patients who are hyperthyroid. This is preferred in lesions in the superior or mediastinal masses. * Fine needle biopsy This tool is used to get samples from the cystic mass found in the thyroid gland.

Treatment * Medical since enlargement of the thyroid gland is mainly due to hormonal imbalance, your doctor may prescribe medications to increase or decrease production of thyroid hormones. A patient may also be prescribed with medication to control some of the symptoms. * Surgical in some instances, when the size of the thyroid gland causes compressive symptoms (difficulty breathing, difficulty swallowing, or hoarseness), it becomes an indication for surgically removing a part or the entire thyroid gland.This is most important especially among patients who were diagnosed with cancer.

Prevention * Nutrition eating Iodine-rich foods and avoiding goitrogenic foods. Adding Iodized salt instead of the regular salt is also better especially in the areas where iodine-rich food are scarce. * Always seek a physician when you notice you neck is larger than it used to be or when you are able to palpate a mass along the anterior neck area. Early recognition will increase the chance of cure.

References: The Mayo clinic staff. Goiter. http://www.mayoclinic.com/health/goiter/DS00217. January 8, 2011 Mulinda, James MD, FACP, FACE, et al. Goiter. Medscape Reference: Drugs, Diseases, and Procedures.http://emedicine.medscape.com/article/120034-overview.