Goiter

The main distinguishing feature of goiter is a swollen thyroid gland that appears as a lump at the front of the neck. It does not present any symptoms if the swelling is small. The size of the goiter may vary from person to person. In some cases, the enlarged thyroid gland obstructs the respiratory tract and larynx (voice box) and can cause symptoms such as:

• Coughing
• Tight feeling in the throat
• Difficulty in swallowing
• Difficulty in breathing
• Hoarseness
• Snoring

Some symptoms depend on changes in thyroid function. People with goiter can have either an underactive (hypothyroidism) or overactive (hyperthyroidism) thyroid gland. However, both hypothyroidism and hyperthyroidism can develop without goiter.

Symptoms of hypothyroidism include:

• Tiredness
• Weight gain
• Constipation
• Body aches
• Dry skin
• Increased sensitivity to cold
• Muscle weakness

Symptoms of hyperthyroidism include:

• Weight loss
• Sweating
• Shortness of breath
• Diarrhea
• Palpitations
• Hair thinning
• Menstrual changes
• Tiredness
• Muscle weakness

Iodine deficiency:

Iodine is a crucial element needed by the thyroid gland to produce thyroid hormones. A lack of iodine in the diet can lead to swelling of the thyroid gland as it attempts to produce enough hormones. Approximately 30% of the world’s population remains at risk of iodine deficiency due to insufficient dietary iodine.

Grave’s disease:

This autoimmune disorder occurs when the body attacks the thyroid gland, resulting in swelling of the gland.

Thyroiditis:

Thyroiditis refers to the inflammation of the thyroid gland, which can predispose individuals to goiter. It can be caused by several factors, including:

• Hashimoto’s thyroiditis (autoimmune disease)
• Infections
• Radiotherapy

Thyroid cancer:

Infiltrating papillary thyroid cancer, lymphoma, and anaplastic thyroid cancer can also be potential causes of goiter.

Medications:

Certain medications, such as lithium, phenylbutazone, and amiodarone, can cause the thyroid gland to swell.

Goitrogenic food:

Goitrogens are food items that can interfere with thyroid function. Excessive consumption of these foods may lead to goiter. Examples include:

• Brussel sprouts
• Kohlrabi
• Turnips
• Strawberries
• Radishes
• Cabbage
• Broccoli
• Kale
• Cauliflower

Gender

The chances of goiter are higher in women than in men when exposed to iodine deficiency. Women have 2 to 10 times more chances of developing it than men.

Age

The association between age and goiter is dependent on iodine status. In cases of severe iodine deficiency, the risk of developing goiter is higher in teenagers.

Smoking

Tobacco smoking is linked to an increased risk of developing goiter due to the formation of thiocyanate in smokers. Thiocyanate leads to iodine deficiency and is an important risk factor in the formation of multiple nodules.

Pregnancy

Pregnancy is a risk factor for goiter in iodine-deficient women. The incidence of goiter can be easily prevented by increasing iodine intake in the diet.

Menopause

Postmenopausal women are at a higher risk of developing goiter.

Family History

Individuals with a family history of thyroid disorders have a higher likelihood of developing goiter.

Radiation

Studies suggest that exposure to radiation (such as during CT scans) of the thyroid gland increases the risk of nodular goiter, particularly in individuals under 20 years of age.

Environment

Exposure to harmful chemicals such as nitrates, benzene, formaldehyde, pesticides, bisphenol A, polychlorinated biphenyl, polyhalogenated aromatic hydrocarbons, and polybrominated diphenyl ether also increases the chances of developing goiter. These chemicals can be consumed through contaminated water, air, and food.

Mutations

Mutations refer to changes in genes, which are units of heredity. Several mutations, including changes in the RAS, SPOP (4/38), ZNF148 (6/38), and EZH1 (3/38) genes, are associated with an increased risk of nodular goiter and benign nodules.

Insulin Resistance and Metabolic Syndromes

Several studies suggest that insulin resistance and other metabolic syndromes, such as obesity, increase the risk of goiter and papillary thyroid cancer. Obesity in both males and females makes individuals more prone to thyroid cancer.

Elevation in Thyroid Stimulating Hormone (TSH)

Elevated levels of TSH increase thyroid volume over time, raising the risk of goiter, especially nodular goiter. This is commonly seen in iodine-sufficient endemic goiter and in obesity, as obese individuals often have higher TSH levels than normal individuals, making them more prone to goiter.

Hyperinsulinemia

Hyperinsulinemia refers to excess insulin secretion in the body. Increased insulin receptor levels have been observed in thyroid cancers and are associated with an increased risk of thyroid nodules.

1. Physical examination & medical history
   The doctor physically examines the patient for any signs of thyroid enlargement. The lymph nodes adjacent to the thyroid gland are also checked. The patient is asked about their medical history and the symptoms they are experiencing for a detailed understanding of the disease.
2. Blood tests
   
   • Thyroid stimulating hormone (TSH): TSH is the principal hormone that regulates the production of thyroid hormones, including triiodothyronine (T3) and thyroxine (T4). High levels of TSH typically indicate an underactive thyroid gland (hypothyroidism). Low levels may result from an overactive thyroid gland (hyperthyroidism).
   • Thyroxine total (T4): Most of the T4 in the blood is attached to a protein called thyroxine-binding globulin. The "bound" T4 cannot enter body cells. Only about 1%-2% of T4 in the blood is unattached ("free") and can enter cells. The free T4 and the free T4 index are simple blood tests that measure how much unattached T4 is available in the blood. In hypothyroidism, thyroxine levels are lower than normal, whereas in hyperthyroidism, they are elevated.
   • Thyroxine total (T3): The Triiodothyronine (T3) Total Test measures the total levels (both free and bound forms) of the triiodothyronine (T3) hormone in the blood and is usually performed as part of the thyroid profile total test.
   Supporting tests may also be required to evaluate and monitor the condition, such as:
   • Anti-thyroglobulin antibody
   • Thyroxine binding globulin
3. Imaging tests
   The following imaging tests can be used to determine the cause of hypothyroidism:
   • Thyroid scan: This test evaluates the size, shape, and position of the thyroid gland using a small amount of radioactive iodine to help diagnose the cause of goiter and check for thyroid nodules.
   • Ultrasound: An ultrasound of the thyroid provides a detailed view of thyroid nodules, which are solid or fluid-filled lumps that form within the thyroid gland. It can also help determine if the nodules are cancerous.
   • Radioactive iodine uptake test: This test measures how much radioactive iodine the thyroid absorbs from the blood after swallowing a small amount. It helps assess thyroid function and identify the cause of goiter.
   • MRI or CT scan: These imaging tests are used if the goiter is very large or has spread to the chest.
4. Biopsy
   During a biopsy, a small amount of tissue is removed from the nodule and examined for the presence of cancer. This procedure is typically recommended if the size of the thyroid nodule exceeds ½ inch.

Take proper diet

The iodine is very essential for the synthesis of thyroid hormones. If deficiency of iodine in diet is the cause of goiter, the following measures can be taken to maintain the iodine levels:

• Use iodized salt: Iodized salt is the major source of iodine in the diet. It has been the mainstay of the prevention of iodine deficiency. The use of iodine-containing supplements is recommended in areas where iodized salt is not available. The recommended dietary allowance (RDA) for iodine in adult men and women is 150 micrograms/day as per The Institute of Medicine. The recommendations are higher for pregnant and breastfeeding women: 220 micrograms/day for pregnant women and 290 micrograms/day for breastfeeding women.
• Consume iodine-rich foods: Iodine is a mineral that is mostly found in soil and oceans, making it available in seafood. Iodine-rich foods should be included in the diet to prevent goiter and other thyroid-related problems such as hypothyroidism. The iodine-rich foods include:
  • Cheese
  • Cows milk
  • Eggs
  • Frozen yogurt
  • Saltwater fish
  • Seaweed (including kelp, dulce, nori)
  • Shellfish
  • Soy milk
  • Soy sauce
• Limit goitrogenic foods: Some foods reduce the absorption of iodine, which can cause goiter. Limiting such foods and avoiding their raw form may help in the prevention of goiter by balancing the body's iodine demand. The common goitrogenic foods include:
  • Cabbage
  • Cauliflower
  • Brussels sprouts
  • Broccoli
  • Turnips
  • Mustard greens
  • Kale
  • Cassava root
  • Lima beans
  • Sweet potato
  • Millet
  • Soy and soy products
  • Green tea
• Avoid overexposure to radiation: Radiation at the workplace or during any treatment can cause several thyroid disorders, including goiter. Avoiding radiation helps prevent goiter.

The cause and size of goiter determine the treatment approach.

Iodine supplements are recommended if the cause is a deficiency of iodine in the diet. These supplements help prevent the enlargement of the thyroid gland; however, reducing the size of an already enlarged gland is challenging.

There are various cases of asymptomatic goiter with normal thyroid function. If such cases are found to be benign on ultrasound, normal follow-up ultrasounds are required depending on the size of nodules, without specific treatment.

Depending on the other conditions causing goiter, the following treatment approaches are discussed in detail:

• Medications
  • Medications for Hyperthyroidism: In cases of overactive thyroid or hyperthyroidism, there is an excess production of thyroid hormones. The objective of the treatment is to control hormone production. Antithyroid medicines such as thionamide, methimazole, and propylthiouracil are prescribed to reduce the function of the thyroid gland.
  • Medications for Hypothyroidism: In hypothyroidism, treatment involves synthetic replacement of thyroid hormone to restore the activity of the underactive thyroid. The common medication used is levothyroxine. The dose is gradually increased to avoid side effects. This hormone helps reduce the size of the enlarged thyroid gland, and symptoms usually begin to improve within the first week of treatment.
  • Anti-inflammatory Medications: In conditions associated with the thyroid, such as thyroiditis, anti-inflammatory medications are used to reduce the size of the thyroid. One commonly used medication is aspirin.
• Radioactive Iodine: Iodine is administered to the patient as a capsule or liquid, which accumulates in the thyroid gland, helping to shrink the enlarged thyroid or goiter.
• Surgery: Surgical removal of the goiter is necessary if its size compresses adjacent cervical structures. This may involve the removal of either the entire thyroid gland or part of it. Thyroid gland surgery is advised in the following conditions:
  • If the nodule of the thyroid gland is cancerous or may become cancerous, as confirmed by biopsy.
  • If the size of the gland has become so large that it causes symptoms such as trouble swallowing, difficulty breathing, or changes in voice due to compression of nearby structures.
  • If the patient with an overactive thyroid does not respond to treatment, as seen in conditions such as Graves’ disease.
• Types of Surgery: The removal of the thyroid gland can be performed in several ways, with a specific type recommended based on the condition of the thyroid gland and overall health.
  • Hemithyroidectomy or Lobectomy: This surgery involves the removal of only one lobe of the thyroid gland and is performed when a nodule is present on one side.
  • Isthmusectomy: This involves the removal of the isthmus, which connects the two lobes of the thyroid, and is useful in cases where small tumors are located only on the isthmus.
  • Total Thyroidectomy: This procedure involves the removal of the entire thyroid gland and is required in cases of thyroid cancer, bilateral thyroid nodules, and Graves’ disease.

Showers with Cold Water

It is advisable to end the shower with cold water targeting mainly the thyroid gland (throat and neck). This practice is known to stimulate blood flow to the thyroid gland and increase the accessibility of essential nutrients, which helps in the smooth functioning of the gland.

Use of Medications

Some medications can trigger goiter, so it is important to monitor any medications taken for other diseases.

Regular Neck Exercises

These exercises help reduce swelling by targeting the tissues of the thyroid gland. It is always best to consult your doctor before including these exercises in your regimen. Some common neck exercises include:

• Upward Neck Stretch:
  • Sit on a chair.
  • Lift your chin towards the ceiling.
  • Stretch the neck as much as possible.
  • Stay in that position for a few seconds.
  • Repeat this exercise 10-12 times.
• Sideways Neck Stretch:
  • Slowly bend your neck to the side.
  • Ensure that your ear touches your shoulder.
  • Stretch as much as possible.
  • Repeat on the other side.
  • Do 10 repetitions on each side.

Note: Avoid overexertion while doing these exercises. Stretch as much as you can without feeling discomfort or pain. Stop the exercise immediately if you experience any pain.

Gentle Massages

Gentle massages over the area of swelling with olive oil or coconut oil are also helpful for patients with an enlarged thyroid gland.

The major complications that can develop due to untreated goiter are:

• Compression of the trachea
• Iodo-Basedow phenomenon, which is the development of hyperthyroidism if exposed to iodine intake
• Intra-nodular hemorrhage or necrosis

Complications due to hyperthyroidism:

• Bulging eyes, blurred vision, double vision, or even vision loss
• Tachycardia and problems with heart rhythm
• Osteoporosis
• Red and swollen skin
• Thyrotoxic crisis

Complications due to hypothyroidism:

• Hypercholesterolemia
• Tingling sensation in the nerves
• Infertility
• Birth defects
• Miscarriage
• Depression
• Myxedema

Read more about complications of hypothyroidism. Read To Know!

Complications Associated With Thyroid Surgery

Thyroid surgery is a safe procedure; however, it is associated with certain risks which include:

• Bleeding in the neck
• Hoarseness/voice change
• Hypocalcemia
• Seromas
• Infection

Home Remedies

• Apple cider vinegar: It is mildly acidic and helps restore the pH balance of the body. It aids in balanced hormone production and increases iodine absorption, which may reduce swelling. It can be consumed with honey and warm water, preferably on an empty stomach.
• Castor (Arandi) oil: This oil reduces swelling of the thyroid gland due to its anti-inflammatory properties. It should be massaged around the swollen neck area and left overnight until the swelling decreases.
• Coconut (Nariyal) oil: Rich in medium-chain fatty acids, it supports the proper functioning of the thyroid gland and possesses anti-inflammatory and antimicrobial properties. It can improve metabolism and can be added to hot drinks, smoothies, or used in cooking for health benefits.
• Bentonite clay: This natural clay has antimicrobial properties and is useful in goiter due to its ability to absorb toxins, which helps reduce swelling. A smooth paste made by adding water is applied to the swollen area and rinsed off after drying.
• Seaweed: A good source of iodine, it aids in the production of thyroid hormones and contains amino acids like tyrosine that support hormone production. It can be consumed as a salad or added as a dressing.
• Dandelion leaves: These leaves help reduce swelling of the thyroid gland due to their antioxidant and anti-inflammatory properties. They can be ground with water to make a paste that is applied to the neck.
• Lemon juice: This juice helps remove toxins that may be present due to infection in the thyroid gland and possesses antimicrobial properties that can help eliminate microbes in the gland.
• Turmeric (Haldi): Known for its healing properties, turmeric reduces swelling of the thyroid gland due to its anti-inflammatory nature.
• Garlic (Lehsun): Garlic stimulates the production of glutathione in the body, which increases selenium levels necessary for the normal functioning of the thyroid gland.

Acupuncture

Acupuncture is known to ease the symptoms of goiter; however, its efficacy requires more relevant research.

Goiter is not a very severe disease, but it is not something that can always be treated without the right medical intervention. It is necessary to visit the doctor for the correct diagnosis and effective treatment.

Correcting Iodine Levels

It is not always necessary that the cause of goiter is iodine deficiency. After consultation with the doctor, he or she will guide you about the recommendations of iodine needed by your body. It is essential to correct the iodine levels to make the treatment plan work. The following measures should be considered for correcting iodine levels:

• The recommended daily serving of iodine is 150 mcg/day for adults. It helps in the normal functioning of the thyroid gland. If the goiter is caused by malnutrition, then getting enough iodine could help treat it.
• If iodine deficiency is diagnosed as the cause of goiter, do not start taking supplements without medical consultation. Too much iodine can also cause several thyroid problems.
• The main source of iodine is iodized salt. Switch to iodized salt if you are using non-iodized salt to meet your daily iodine needs. Frozen and processed foods are usually very salty, but in most cases, they do not use iodized salt. Do not rely on these food items for your daily iodine intake.
• If the cause of goiter is excess iodine, it is advised to reduce iodine intake. Measures such as switching from iodized to non-iodized salt and reducing the intake of seafood and seaweed can be taken.
• Consult your doctor to cut your iodine intake if the cause of goiter is found to be excess iodine.
• The excess consumption of salt can also cause several other health problems, so take it according to recommendations.

Post-operative Care

Patients who have undergone surgery are advised to limit their physical activity. The patient can gradually resume their lifestyle, including exercise and physical activity, as per the surgeon’s indications.

Post-operative Medications

In the case of thyroidectomy, where the entire thyroid gland is removed, lifelong thyroid supplements are required. Sometimes, calcium supplements are also necessary for patients after surgery, depending on calcium levels.

Lifestyle Modifications

Some lifestyle changes are required for the smooth functioning of the thyroid gland, including:

• Limiting alcohol
• Limiting smoking
• Eating healthy

Planning While Traveling

Patients with goiter can travel normally but are recommended to carry medications for the entire trip. Patients who have undergone surgery should pack their thyroid supplements with them.

Goiter During Pregnancy

Pregnant women should inform their endocrinologist about their condition well in advance. This will help the doctor create a customized treatment plan for them.