Goitre

Also written as Thyroid enlargement, Nontoxic goitre.

Enlargement of the thyroid gland with varied causes. In low‑resource settings iodine deficiency, infections and goitrogenic drugs are common. Assessment focuses on size, function and red‑flag features.

Overview

Goitre is any palpable enlargement of the thyroid. It may be diffuse or nodular and can be euthyroid, hyper‑ or hypothyroid. In East Africa iodine deficiency remains the leading cause, but infection, autoimmune disease and drug exposure are also frequent.

• Diffuse goitre → often functional (e.g., Graves, iodine deficiency)
• Nodular goitre → risk of malignancy, usually euthyroid

Key concepts

Diagnosing goitre requires a systematic history, focused neck exam and targeted investigations. Severity is staged by size (palpable, visible, >4 cm) and by functional status (euthyroid, hyper, hypo).

• Thyroid function tests (TSH, free T4): Is the gland over‑ or under‑producing hormone? Low TSH = hyperthyroidism; high TSH = hypothyroidism
• Serum thyroglobulin: Helps monitor differentiated thyroid cancer; not routinely available, use clinical follow‑up instead
• Ultrasound of neck: Distinguishes solid vs cystic nodules, assesses size and vascularity; if unavailable, rely on palpation and clinical suspicion
• Fine‑needle aspiration cytology (FNAC): Detects malignancy in nodules >1 cm or suspicious features; if not possible, refer for surgical assessment

• History: diet, family thyroid disease, radiation, drug exposure, symptoms of hypo‑/hyper‑thyroidism
• Examination: assess symmetry, consistency, bruit, eye signs, skin changes

Clinical relevance

In low‑resource hospitals the most urgent tasks are to identify life‑threatening hyperthyroidism (thyrotoxic crisis) and to rule out compressive symptoms that may compromise airway or cause venous congestion.

• Rapid bedside thyroid exam: Detects bruit or thrill suggesting Graves disease; if present, prioritize antithyroid treatment
• Serum calcium (if surgery planned): Identifies hypocalcaemia risk after thyroidectomy; if unavailable, monitor for tetany clinically

• Airway obstruction → urgent ENT review
• Thyrotoxic crisis → beta‑blocker and antithyroid therapy

Exam pearls

Examiners test your ability to integrate history, exam and limited investigations, and to prioritize management in resource‑constrained settings.

• Always comment on size, consistency, mobility and presence of bruit
• Link iodine deficiency to endemic regions and dietary habits

Common mistakes

Students often list causes without prioritising likely local aetiologies, forget to assess thyroid function, or assume all nodules are malignant.

• Neglecting to ask about goitrogenic foods (cassava, millet) and herbal remedies
• Over‑reliance on ultrasound when not available

Questions an examiner may ask

• A 28‑year‑old farmer presents with a diffuse neck swelling and tremor. What is your next step and why? — Check TSH to differentiate Graves disease from simple iodine‑deficiency goitre; treat hyperthyroidism if TSH suppressed.
• A patient with a 5 cm nodular goitre has normal TSH. How do you assess cancer risk without ultrasound? — Perform FNAC if the nodule is >1 cm or has suspicious features; if FNAC unavailable, refer for surgical opinion.
• During a ward round you notice a patient with a goitre and new‑onset hoarseness. What does this indicate and what action is required? — Possible recurrent laryngeal nerve involvement or compression; arrange urgent airway assessment and ENT review.
• In a region with endemic iodine deficiency, a child presents with a small goitre and normal thyroid function. What public health measure would you recommend? — Iodine supplementation through iodised salt or community fortification.
• A pregnant woman develops a rapidly enlarging goitre. Which investigation is safest and what are management priorities? — Ultrasound (no radiation) to assess nodule; monitor thyroid function and treat hypo‑ or hyper‑thyroidism to protect mother and fetus.
• You suspect thyroiditis in a patient with painful goitre and fever, but CRP is unavailable. How do you proceed? — Rely on clinical signs (tenderness, warmth) and consider empirical NSAIDs; if worsening, arrange drainage for suppurative infection.
• A patient on lithium presents with a diffuse goitre. What is the mechanism and how should you manage it? — Lithium interferes with thyroid hormone synthesis causing goitre; review lithium need, consider dose reduction or switch, and monitor TSH.
• Explain why a low‑resource hospital might prioritize a bedside thyroid exam over laboratory tests in an acute setting. — Immediate assessment of size, bruit and compressive signs guides urgent interventions when labs are delayed.

When to seek help

• Sudden increase in size with dysphagia or stridor
• Signs of thyrotoxic crisis (fever, tachycardia, agitation)
• Neck pain with fever suggesting suppurative thyroiditis

Quick questions

Is every goitre due to iodine deficiency?

No; common causes include Graves disease, multinodular goitre, Hashimoto thyroiditis, drugs (e.g., lithium) and infections.

Can a patient have a large goitre and be clinically euthyroid?

Yes; most multinodular goitres are euthyroid, but periodic testing is needed.

When is surgery indicated?

For compressive symptoms, suspicion of cancer, or a rapidly growing nodule despite medical therapy.