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