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 approximately 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.
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- 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
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS