Enlargement

Enlargement

General
A goiter is an enlargement of the thyroid gland. This enlargement can be smooth and uniform (diffuse goiter) or it can be caused by one or more lumps within the gland (nodular goiter). When there are many small lumps in the gland, it is also called a multinodular goiter. The presence of a thyroid goiter does not affect the functioning of the thyroid gland itself, however. The gland may be underactive, overactive, or functioning normally.

Symptoms
People with a small goiter will usually not have any symptoms. If a goiter grows and becomes larger, you may experience various symptoms, such as problems with swallowing and shortness of breath. It may also cause cosmetic concerns because a goiter can lead to visible swelling in the neck. 

Tests and diagnosis
The attending physician will make a diagnosis based on the symptoms, a physical examination, and an ultrasound or CT scan of the neck. In addition, blood tests will be performed to determine whether the thyroid gland is overactive or underactive. If the thyroid is overactive, an additional scan to assess iodine uptake by the thyroid gland (thyroid scintigraphy) may be required. 

Blood tests
The thyroid gland produces a number of thyroid hormones that can be measured in the blood. If there is a nodule in the thyroid, the level of these hormones may be elevated, depressed, or normal. The next steps will be worked out depending on the results of the blood test.

Ultrasound
An ultrasound is performed at the radiology department. During the examination you will be asked to lie down on the ultrasound table. A transparent gel will be applied to your neck. The radiologist will then move an ultrasound probe over your neck. The ultrasound device emits sound waves. These sound waves are bounced back through the body and the echoes are picked up by the probe. The thyroid gland is displayed on the monitor. The ultrasound is used to find out what the goiter looks like. The goiter is also measured. This procedure is not painful. You do not need to fast before this procedure.

Puncture biopsy
To determine whether a goiter is benign or malignant, one of the lumps (nodules) must be punctured. This is called a puncture biopsy. The radiologist will use an ultrasound probe to locate the nodule and then puncture the nodule with a thin needle. This is similar to drawing blood from a vein. No anesthetic will be given for this procedure as it would mean puncturing the skin with two needles. Cells are collected from the nodule through a needle. Sometimes it is not possible to collect enough cells in one go and a second puncture will be necessary. There is a small chance that the puncture may cause bleeding in the neck. If the swelling in the neck increases after the puncture, you should contact the hospital. If you are on blood thinning medication, it is important that you inform the physician of this prior to the puncture. Not all nodules will require a puncture.

Thyroid scan
A thyroid scan will usually be performed when thyroid hormone levels are elevated. This is also called a scintigraphy. The thyroid scintigraphy will be performed in the nuclear medicine department, where a radioactive substance will be administered. This substance can be administered in different ways. Sometimes you will be asked to swallow radioactive iodine in the form of a capsule. In this case, you will have to return the next day for the scintigraphy to be performed. This is because the radioactive substance must first be absorbed by the thyroid gland.

You can also have the radioactive substance injected into your bloodstream. The substance will then also need to be absorbed, but this only takes 20 minutes. The scan will determine whether the thyroid nodule is producing hormones.

Treatment
If a benign goiter is not causing any symptoms, it will not need to be treated. However, if the goiter is causing symptoms, there are various treatment options. It is possible to reduce the size of the goiter using radioactive iodine. The effect of this treatment will become clear after several weeks or months. Whether iodine treatment is an option will depend on how well the goiter can absorb radioactive iodine, among other things. Your internist/endocrinologist will discuss with you whether this treatment is appropriate for you.

It is also possible to surgically remove the entire thyroid gland or half of it, depending on where the enlargement is located. This surgical procedure will be chosen if iodine treatment is not possible, and when a rapid solution is preferable.

Click here for the patient leaflet (Dutch) on thyroid nodules and goiters published by the Dutch Association for Endocrinology (NVE).