Simple hyperplastic goitre

The patient presents with a swelling in the neck. Physiological causes include puberty and pregnancy. Iodine deficiency is the most common cause but is rare in the UK, where iodide is added to table salt. Where the condition is endemic (often in isolated mountainous regions such as Nepal), iodine deficiency is the usual cause.

Multinodular goitre

This is the commonest cause of goitre in the UK. It is more common in women. The usual presentation is a lump in the neck, which moves on swallowing, but with a very large gland, the patient may complain of dyspnoea or dysphagia.

Toxic goitre

The patient presents with a lump in the neck. He or she may indicate a preference for cold weather, and may also complain of excessive sweating, tiredness, anxiety, increased appetite, weight loss, diarrhoea, palpitations and tremor.

Autoimmune

Hashimoto’s disease presents with a firm goitre. It needs to be distinguished from lymphoma. Eventually, the patient becomes hypothyroid, and will complain of intolerance to cold weather, tiredness, a change in voice (hoarseness), weight gain, constipation, dry skin and dry hair.

Neoplastic goitre

The patient may present with diffuse enlargement of the thyroid or may have noticed a well-defined swelling in the area of the thyroid gland. Papillary carcinoma occurs in the younger patient (under 35 years) and, in addition to the goitre, the patient may have noticed lymph node swelling in the neck. Follicular carcinoma occurs in middle age (40–60 years). The patient may also complain of bone pain due to metastases. Anaplastic carcinoma occurs in the elderly. Anaplastic carcinoma may present with stridor, dyspnoea and hoarseness. There may be gross lymph node involvement. Medullary carcinoma can present at any age. Check for a family history of medullary carcinoma and symptoms related to phaeochromocytoma and hyperparathyroidism (associated MEN syndrome). Lymphoma of the thyroid is rare and may develop in pre-existing autoimmune (Hashimoto’s) thyroiditis.

Inflammatory (rare)

The patient may present with a painful swelling of the thyroid associated with malaise or myalgia (de Quervain’s thyroiditis). A hard mass associated with dysphagia or dyspnoea may suggest Riedel’s thyroiditis.

Simple hyperplastic goitre

The patient is usually euthyroid and the goitre is smooth. Where the condition is endemic, the goiters are often asymmetrical and soft to palpation. They are composed of many large hyperplastic nodules and can reach enormous size (Fig. 25).

Multinodular goitre

The gland is usually smoothly nodular. Occasionally only one nodule may be felt – the dominant nodule in a multinodular goitre. Check for tracheal deviation when the gland is large, and percuss for retrosternal extension.

Toxic goitre

Palpation of the gland may reveal a diffuse goitre, a multinodular goitre or a solitary nodule. Check for exophthalmos, lid lag, lid retraction, warm moist palms and tremor. Check for atrial fibrillation. Examine for pretibial myxoedema. Reflexes are brisk. The goitre may have a palpable thrill or a bruit may be heard on auscultation.

Autoimmune

Hashimoto’s disease presents with a diffusely enlarged, firm gland. Eventually, there may be signs of hypothyroidism. These signs include a pale, waxy skin, periorbital oedema, dry thickened skin and hair, slow pulse, large tongue, peripheral oedema and slow relaxing reflexes. Carpal tunnel syndrome may be present.

Neoplastic goitre

There may be a solitary thyroid nodule (papillary carcinoma) or a more diffuse mass (follicular carcinoma). Anaplastic carcinoma is hard and irregular and invades locally. Check for tracheal deviation. Cervical lymphadenopathy may be present with a papillary carcinoma, when the glands are usually mobile and discrete, and is invariably associated with anaplastic carcinoma, where the glands may be hard and matted. Check for recurrent laryngeal nerve palsy – has the patient got a hoarse voice or is unable to produce an occlusive cough?

Inflammatory

Subacute thyroiditis (rare). There will be a painful, swollen gland. In Riedel’s thyroiditis, there is a woody, hard goitre, which infiltrates into adjacent muscle. It must be carefully differentiated from anaplastic carcinoma.

■ FBC, ESR
Hb ↓ in disseminated malignancy. ESR ↑ in thyroiditis.

■ TFTs
T₄ ↑, TSH ↓ in toxic goitre. T₄ ↓, TSH ↑ in hypothyroidism.

■ Thyroid antibodies
Thyroid antibodies will be demonstrated in Hashimoto’s disease.

■ CXR
Secondary deposits in thyroid carcinoma (follicular, anaplastic).

■ Thoracic inlet X-ray
Tracheal compression.

■ US
Cystic versus solid. Position of gland.

■ CT scan
Position of gland. Compression/invasion of local structures.

■ Radioisotope scan
Hot versus cold nodule. Cold nodules may be malignant.

■ FNAC
Benign versus malignant.

■ Laryngoscopy
Involvement of recurrent laryngeal nerve.

■ Serum calcitonin
Calcitonin ↑ in medullary carcinoma.

■ PTH
Raised in MEN syndrome.