What are the symptoms of thyroid goiter and all you need to know

Goiter is defined as a diffuse and major volumetric increase in the thyroid gland that cannot be attributed to inflammatory or neoplastic processes. Usually, precisely because of its large size, it causes dislocation and/or compression on neighboring organs (trachea, esophagus). 

“We distinguish a diffuse goiter, an enlarged gland in toto without nodules, from multinodular goiter, characterized by multiple nodules, most often bilateral and confluent. The term “goiter” reflects only the structural thyroid aspect, whereas in functionally, goiter can be normo, hypo, or hyperfunctioning,” the Dr. Savulescu points out.

Goiter is the most frequent clinical manifestation of iodine deficiency, a trace element essential for the synthesis of thyroid hormones. 

The main source of iodine is food, and the daily requirement is 150-200 μg (micrograms). This requirement may vary with age, during pregnancy and while breastfeeding. The use of iodine-fortified salt (30 mg I/Kg) helps to overcome this issue. In Italy, since 2005, through a legislative measure, iodized salt has been marketed.

“Insufficient dietary iodine intake results in iodine deficiency disorders ranging from endemic goiter to hypothyroidism and cretinism (neurological and mental deficits of varying degrees resulting from iodine deficiency during pregnancy and early life with impaired development of the nervous system),” the specialist points out.

Other risk factors are familiarity and female gender: familial goiter is found in multiple members of the same family and is correlated with inherited transmission of defects in thyroid hormone synthesis. Goiter is more common in the female sex, manifesting itself during puberty and pregnancy.

Finally, goiter may also be related to nutritional factors, specifically chronic and very large intakes of foods containing thiocyanates: broccoli, turnips, cabbage. There are also less frequent forms of goiter caused by taking antithyroid drugs containing iodine and iodide.

The appearance of a swelling in the anterior region of the neck, at its base, found independently by the patient or during a medical examination, allows for identification of thyroid goiter.

“Only occasionally there may be a sudden rise of the gland accompanied by pain, without signs of local inflammation or fever. In these cases we talk about the appearance of a cystic lesion or bleeding within cysts or nodules already present in the goiter,” the specialist specifies.

Aesthetic appearance may be more or less impactful. With the development of thyroid replacement therapy (synthetic thyroid hormone that replaces physiological thyroid secretion) and the improvement of surgical techniques, which are less and less invasive, it is difficult or at any rate very rare in today's day and age to find the voluminous thyroid goiters of the past. 

Symptoms, however, may be related to both the structural aspect (the size) of the thyroid goiter and the functional aspect of the thyroid.

Symptoms in voluminous goiter

The symptoms related to voluminous goiter are due to:

• tracheal dislocation and compression with related dyspnea (difficulty in breathing), especially in some neck movements or in supine position, nighttime, with the need to sleep with multiple pillows;
• compression exerted by the struma (or goiter) on the recurrent nerves (nerves bordering the trachea and therefore in close contact with an enlarged thyroid gland, whose function is to enable us to speak by ensuring vocal cord motility, coughing, or swallowing) resulting in dysphonia and difficulty in swallowing;
• compression, less frequent and for very bulky goiters, of the esophagus with subsequent dysphagia; 
• mediastinal involvement due to goiters that deepen into the chest, retrosternal ones, with subsequent compression of the vessels and jugular turgor or congestion of the face;
• possible neoplastic transformation of goiter nodules. 

“Thyroid cancers are generally not very aggressive and have a relatively favorable prognosis. They account for about 1.5% of all malignancies and annual mortality is 0.3% of all cancer deaths, 20-year survival is more than 80%; they are more frequent in the female sex especially at a young age,”  Dr. Savulescu explains.

Symptoms related to thyroid function

In addition to the symptoms due to the structural appearance of the goiter and its size, the functional thyroid aspect should also be evaluated. More often, goiter is accompanied by normal thyroid function. As the number of nodules and size of the stuma increase, the appearance of thyroid hyperfunction, or hyperthyroidism, may occur.

“This condition is more frequent in long-standing goiters and in older patients who present predominantly cardiological symptoms, often diagnosed precisely during cardiological diseases (atrial fibrillation),” explains the specialist.

The following forms can be found:

• forms with overt hyperthyroidism, in the case of toxic multinodular goiter (excessive thyroid hormone production with suppressed TSH);
• milder forms, with subclinical hyperthyroidism (TSH suppressed, but thyroid hormones still in the normal range) in the case of multinodular goiter in the pretoxic phase. 

“The functional aspect also plays an important role in neonatal and juvenile age and is related to the severity, duration, and period of exposure to iodine deficiency. This can result in: miscarriage / stillbirth, increased perinatal mortality, cretinism (delayed psychomotor and mental development); or, in school/adolescent age goiter, hypothyroidism, variable mental retardation (low IQs, defect in attention, learning, and delayed reaction time), growth retardation,” Dr. Savulescu concludes.

Compared with other conditions, thyroid goiter is easy to detect, and it is often the persom who suffers from it notices it simply by looking in the mirror or touching their neck. 

Although the diagnosis of goiter is often made by palpation self-diagnosis by the patient or occasional finding during a medical examination or during different investigations (cardiologic pathology or TSA EchoDoppler), goiter should always be evaluated and confirmed by ultrasound of the neck. 

The diagnostic examination is easy to perform, quick, inexpensive, and allows for evaluation of:

• size of the struma (goiter);
• presence of nodules and their characteristics (size, echogenicity / structure, margins, vascularity, presence or absence of suspicious features/calcifications);
• relationships between the thyroid gland and surrounding structures (tracheal dislocation, mediastinal involvement, presence of parathyroid gland changes or lymphadenopathy). 

To make a correct and accurate diagnosis, it is important to evaluate the clinical data (thyroid objectivity with size/consistency/nodularity and mobility of the gland, the presence of laterocervical or supraclavicular lymph nodes), the medical history data (family history, age, origin), and the hematochemical data (thyroid function tests: TSH, FT4 and FT3; if nodules are present, calcitonin should also be performed; to complete the investigations, it is advisable to perform Ab anti TPO or anti TSH receptor in hyperthyroidism). Iodide assay, for assessment of iodine deficiency, should be reserved for special situations such as pregnancy and lactation. 

Diagnosis of thyroid nodules

“Finding of thyroid nodules may require cytological framing by ultrasound-guided thyroid needle aspiration. A voluminous stuma, especially if asymmetric and unilateral, also necessitates a neck radiograph to assess the course and caliber of the tracheal tape. 

Currently, thyroid scintigraphy should be reserved for the differential diagnosis of hyperthyroidism or in thyroid oncology follow-up. Such investigations as CT or MRI do not find an indication in routine thyroid evaluation. It may only be required preoperatively for endothoracic goiters.

Ultrasound remains the main thyroid examination: it can also assess the hardness of nodules by elastosonography and their vascularity by Echocolor Doppler, indispensable data in defining the benign or malignant nature of thyroid nodules,” specifies Dr. Savulescu.

Prevention, rather than treatment, is the best measure likely to eradicate endemic goiter (related to iodine deficiency).

“A medium-sized, relatively stable goiter in a patient's young/adult years can continue with annual ultrasound and TSH follow-up. Medical therapy (administration of levothyroxine, a synthetic thyroid hormone) is indicated in the case of small nodules in young patients, and TSH values are indicative of subclinical hypothyroidism (elevated TSH/borderline with normal free fractions of thyroid hormones),” the specialist explains.

There are cases where monitoring the pathology over time is not enough.

“A voluminous symptomatic goiter or a gradual volumetric increase requires thyroidectomy surgery. Likewise in the case of the finding of a nodular cytology suspicious for carcinoma.

In elderly patients with contraindication to surgery, minimally invasive techniques such as thermoablation can be used for volumetric reduction of nodules by radiofrequency (RFA) in the presence of benign nodules. This technique involves the use of heat delivered inside the nodule and determining the coagulative necrosis of the thyroid tissue, which will be replaced by fibrous-catalytic tissue,” Dr. Savulescu continues.

It is important to season food with little salt, but iodized one.​ The same must be done in industrial/ultra-processed prepared foods: it is good that they contain this type of salt. In addition, iodine deficiency should be evaluated during pregnancy, as well as in developing children in endemic areas. Furthermore, it is advisable to moderate the consumption of:

• cruciferous vegetables (cabbage, broccoli, cauliflower, kale, Brussels sprouts), which are to be consumed in a limited manner, and not raw, because they contain goitrogenic substances that can inhibit iodine absorption by the thyroid gland;
• coffee and soy for patients on levothyroxine therapy, as they limit the absorption of the drugs; 
• algae, which, with their iodine content, can interfere both positively and negatively with thyroid hormone biosynthesis.

Watch out for autoimmune forms of dysthyroidism (Hashimoto's thyroiditis) that may be associated with other autoimmune conditions (celiac disease requiring gluten-free diet) or intolerances (lactose intolerance). It is also preferable to consume: 

• fish (especially sardines, trout, tuna, and salmon) for their omega-3 and selenium content;
• potatoes, beans and nuts (walnuts and hazelnuts), again for their selenium intake;
• substances containing calcium and vitamin D (milk and/or dairy products).