Clinical presentation and evaluation of goiter in adults
- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
The term goiter refers to abnormal growth of the thyroid gland. Goiters can be diffuse or nodular, depending on the cause, and may be associated with normal, decreased, or increased thyroid hormone production. The clinical manifestations vary with thyroid function and with the size and location of the goiter. The evaluation of the adult with goiter will be reviewed here. The treatment of goiter in adults and the evaluation and treatment of goiter in children are reviewed separately. (See "Treatment of nontoxic, nonobstructive goiter" and "Treatment of obstructive or substernal goiter" and "Treatment of toxic adenoma and toxic multinodular goiter" and "Congenital and acquired goiter in children".)
In healthy adults without iodine deficiency, a normal thyroid gland is approximately 4 to 4.8 x 1 to 1.8 x 0.8 to 1.6 cm in size, with a mean sonographic volume of 7 to 10 mL and weight of 10 to 20 grams [1,2]. Thyroid volume measured by ultrasonography is slightly greater in men than women, increases with age and body weight, and decreases with increasing iodine intake. (See "Technical aspects of thyroid ultrasound", section on 'Estimation of thyroid gland volume'.)
The normal thyroid gland is immediately caudal to the larynx and encircles the anterolateral portion of the trachea (figure 1). The thyroid is bordered by the trachea and esophagus posteriorly and the carotid sheath laterally. Enlarging thyroid lobes usually grow outward because of their location in the anterior neck in front of the trachea, covered only by thin strap muscles, subcutaneous tissue, and skin. As a result of this outward growth, even very large goiters may not compress the trachea or impinge on the great vessels lateral to the lobes. However, in patients with substantial enlargement of one lobe or asymmetric enlargement of both lobes, the trachea, esophagus, or blood vessels may be displaced or, less often, compressed. Bilateral lobar enlargement, especially if the goiter extends posterior to the trachea, may cause either compression or concentric narrowing of the trachea or compression of the esophagus or jugular veins.
The thoracic inlet is an ovoid area that measures approximately 5 x 10 cm bounded by the sternum anteriorly, the first thoracic vertebral body posteriorly, and the first ribs laterally (figure 2). The inlet is traversed by the trachea, esophagus, blood vessels, and nerves. The inferior pole of each thyroid lobe normally lies above the thoracic inlet. However, with some goiters, there is growth of one or both lobes through the inlet into the thoracic cavity, which can result in obstruction of any of the structures in the inlet. Such goiters are called substernal, although retrosternal is probably a more precise term. Most substernal goiters are in the anterolateral mediastinum, but about 10 percent are located primarily in the posterior mediastinum [3,4]. The prevalence of substernal goiter as a percentage of thyroidectomies ranges from 2 to 19 percent .
Iodine deficiency is the most common cause of goiter worldwide. In mildly and moderately iodine-deficient regions in Denmark, goiter (as determined by ultrasonography) is present in 15 and 22.6 percent of the population, respectively  (see "Iodine deficiency disorders", section on 'Diffuse and nodular goiter'). In the United States, where significant iodine deficiency does not exist, multinodular goiter, chronic autoimmune (Hashimoto’s) thyroiditis, and Graves’ disease are more common causes of goiter. In older adults, multinodular goiter is most common.
- Maravall FJ, Gómez-Arnáiz N, Gumá A, et al. Reference values of thyroid volume in a healthy, non-iodine-deficient Spanish population. Horm Metab Res 2004; 36:645.
- Berghout A, Wiersinga WM, Smits NJ, Touber JL. Determinants of thyroid volume as measured by ultrasonography in healthy adults in a non-iodine deficient area. Clin Endocrinol (Oxf) 1987; 26:273.
- Katlic MR, Grillo HC, Wang CA. Substernal goiter. Analysis of 80 patients from Massachusetts General Hospital. Am J Surg 1985; 149:283.
- White ML, Doherty GM, Gauger PG. Evidence-based surgical management of substernal goiter. World J Surg 2008; 32:1285.
- Knudsen N, Perrild H, Christiansen E, et al. Thyroid structure and size and two-year follow-up of solitary cold thyroid nodules in an unselected population with borderline iodine deficiency. Eur J Endocrinol 2000; 142:224.
- Marqusee E, Benson CB, Frates MC, et al. Usefulness of ultrasonography in the management of nodular thyroid disease. Ann Intern Med 2000; 133:696.
- ul Haq RN, Khan BA, Chaudhry IA. Prevalence of malignancy in goitre--a review of 718 thyroidectomies. J Ayub Med Coll Abbottabad 2009; 21:134.
- Berghout A, Wiersinga WM, Smits NJ, Touber JL. Interrelationships between age, thyroid volume, thyroid nodularity, and thyroid function in patients with sporadic nontoxic goiter. Am J Med 1990; 89:602.
- Elte JW, Bussemaker JK, Haak A. The natural history of euthyroid multinodular goitre. Postgrad Med J 1990; 66:186.
- Lindskog GE, Goldberg IS. Differential diagnosis, pathology, and treatment of substernal goiter. JAMA 1957; 163:327.
- Katlic MR, Wang CA, Grillo HC. Substernal goiter. Ann Thorac Surg 1985; 39:391.
- Allo MD, Thompson NW. Rationale for the operative management of substernal goiters. Surgery 1983; 94:969.
- Shaha AR, Burnett C, Alfonso A, Jaffe BM. Goiters and airway problems. Am J Surg 1989; 158:378.
- Torre G, Borgonovo G, Amato A, et al. Surgical management of substernal goiter: analysis of 237 patients. Am Surg 1995; 61:826.
- Torres A, Arroyo J, Kastanos N, et al. Acute respiratory failure and tracheal obstruction in patients with intrathoracic goiter. Crit Care Med 1983; 11:265.
- Shambaugh GE 3rd, Seed R, Korn A. Airway obstruction in substernal goiter. Clinical and therapeutic implications. J Chronic Dis 1973; 26:737.
- Banks CA, Ayers CM, Hornig JD, et al. Thyroid disease and compressive symptoms. Laryngoscope 2012; 122:13.
- Al-Bazzaz F, Grillo H, Kazemi H. Response to exercise in upper airway obstruction. Am Rev Respir Dis 1975; 111:631.
- Shaha AR. Thyroidectomy decreases snoring and sleep apnea: fact or fantasy? Thyroid 2012; 22:1093.
- Reiher AE, Mazeh H, Schaefer S, et al. Thyroidectomy decreases snoring and sleep apnea symptoms. Thyroid 2012; 22:1160.
- Siderys H, Rowe GA. Superior vena caval syndrome caused by intrathoracic goiter. Am Surg 1970; 36:446.
- Hegedüs L, Bonnema SJ, Bennedbaek FN. Management of simple nodular goiter: current status and future perspectives. Endocr Rev 2003; 24:102.
- Hegedüs L. Thyroid ultrasound. Endocrinol Metab Clin North Am 2001; 30:339.
- Blum M, Biller BJ, Bergman DA. The thyroid cork. Obstruction of the thoracic inlet due to retroclavicular goiter. JAMA 1974; 227:189.
- Bahn RS, Castro MR. Approach to the patient with nontoxic multinodular goiter. J Clin Endocrinol Metab 2011; 96:1202.
- Bashist B, Ellis K, Gold RP. Computed tomography of intrathoracic goiters. AJR Am J Roentgenol 1983; 140:455.
- Jennings A. Evaluation of substernal goiters using computed tomography and MR imaging. Endocrinol Metab Clin North Am 2001; 30:401.
- Rieu M, Bekka S, Sambor B, et al. Prevalence of subclinical hyperthyroidism and relationship between thyroid hormonal status and thyroid ultrasonographic parameters in patients with non-toxic nodular goitre. Clin Endocrinol (Oxf) 1993; 39:67.
- Park HM, Tarver RD, Siddiqui AR, et al. Efficacy of thyroid scintigraphy in the diagnosis of intrathoracic goiter. AJR Am J Roentgenol 1987; 148:527.
- Miller MR, Pincock AC, Oates GD, et al. Upper airway obstruction due to goitre: detection, prevalence and results of surgical management. Q J Med 1990; 74:177.
- Madjar S, Weissberg D. Retrosternal goiter. Chest 1995; 108:78.
- Blegvad S, Lippert H, Simper LB, Dybdahl H. Mediastinal tumours. A report of 129 cases. Scand J Thorac Cardiovasc Surg 1990; 24:39.
- Wychulis AR, Payne WS, Clagett OT, Woolner LB. Surgical treatment of mediastinal tumors: a 40 year experience. J Thorac Cardiovasc Surg 1971; 62:379.
- Priola AM, Priola SM, Cardinale L, et al. The anterior mediastinum: diseases. Radiol Med 2006; 111:312.
- ANATOMICAL RELATIONSHIPS
- CLINICAL PRESENTATION
- Thyroid dysfunction
- Obstructive symptoms
- APPROACH TO EVALUATION
- History and physical examination
- Initial testing
- - Thyroid function tests
- - Thyroid peroxidase antibodies
- - Thyroid ultrasound
- Additional tests
- - Goiter with worrisome features
- - Goiter with normal TSH
- - Goiter with high TSH
- - Goiter with low TSH
- - Goiter with obstructive symptoms or suspected substernal goiter
- Radiologic testing
- Flow-volume loop
- Fine needle aspiration biopsy
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS