History and presentation

• a goitre indicates an abnormality of the thyroid gland (1)
• many patients are asymptomatic
• as a first step look for whether the thyroid is hypothyroid or hyperthyroid
  • look for features hyperthyroidism or hypothyroidism (1)
• if the thyroid is diffusely enlarged (1)
  • a hyperthyroid state may suggest Graves' Disease
  • a hypothyroid sate may indicate Hashimoto's thyroiditis
• other features however, may include:
  • pain - in association with:
    • haemorrhage into a nodule
    • de Quervain's or rarely, Hashimoto's thyroiditis
    • rapidly growing neoplasm
  • choking attacks - which may occur even with quite small goitres
• large, retrosternal tumours may cause:
  • obstruction of the great veins
  • dysphagia
  • stridor - if more than 75% of the diameter of the trachea is compressed
  • recurrent laryngeal palsy - rare
• features in the history which increase the likelihood that a given nodule represents carcinoma include (3):
  • age < 20 years or >70 years
  • male sex
  • family history of medullary carcinoma or multiple endocrine neoplasia
  • history of radiation exposure to the head and neck
  • symptoms of compression-dysphagia, dyspnoea, cough
• physical findings suggesting carcinoma include (3):
  • rapid growth in size
  • firm or hard nodule
  • fixation of nodule to adjacent structures
  • nodule > 4cm
  • paralysis of vocal cords
  • enlarged cervical lymph nodes

Reference:

• (1) Goiter. American Thyroid Association 2006
• (2) Toxic Nodular Goiter. Endocrine Surgical Unit Of UCLA In Los Angele 2007
• (3) Utiger RD. The Multiplicity of Thyroid Nodules and Carcinomas. New England Journal of Medicine,2005;352:2376-2378