NON-TOXIC NODULAR GOITER

Submitted by : Antas, Wilson Bumatay, Jaffrabel Chua, Kayshel Christine Corpuz, jessielyn Cabalo, joel lyode De Lima, Ginnalyn Estella , marvie Anne

Brief anatomy and physiology of the thyroid gland

The thyroid gland is a butterfly-shaped organ and is composed of two cone-like lobes or wings, lobus dexter (right lobe) and lobus sinister (left lobe), connected via the isthmus. The organ is situated on the anterior side of the neck, lying against and around the larynx and trachea, reaching posteriorly the esophagus and carotid sheath. It starts cranially at the oblique line on the thyroid cartilage (just below the laryngeal prominence, or 'Adam's Apple'), and extends inferiorly to approximately the fifth or sixth tracheal ring.[1] It is difficult to demarcate the gland's upper and lower border with vertebral levels because it moves position in relation to these during swallowing. The thyroid gland is covered by a fibrous sheath, the capsula glandulae thyroidea, composed of an internal and external layer. The external layer is anteriorly continuous with the lamina pretrachealis fasciae cervicalis and posteriorolaterally continuous with the carotid sheath. The gland is covered anteriorly with infrahyoid muscles and laterally with the sternocleidomastoid muscle also known as sternomastoid muscle. On the posterior side, the gland is fixed to the cricoid and tracheal cartilage and cricopharyngeus muscle by a thickening of the fascia to form the posterior suspensory ligament of Berry.[2][3] The thyroid gland's firm attachment to the underlying trachea is the reason behind its movement with swallowing.[4] In variable extent, Lalouette's Pyramid, a pyramidal extension of the thyroid lobe, is present at the most anterior side of the lobe. In this region, the recurrent laryngeal nerve and the inferior thyroid artery pass next to or in the ligament and tubercle.

Definition of non-toxic nodular goiter

Nontoxic Nodular Goiter or sporadic goiter; simple goiter; nodular enlargement of the Thyroid Gland A nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function. Endemic goiter is defined as thyroid enlargement that occurs in more than 10% of a population, and sporadic goiter is a result of environmental or genetic factors that do not affect the general population.

Diffuseenlarging the whole thyroid gland Nodularenlargement caused by nodules, or lumps, on the thyroid

The development of nodules marks a progression of the goiter. It should be evaluated by your doctor.

Goiter (Enlargement of the Thyroid Gland)

Pathophysiology
The histopathology varies with etiology and age of the goiter. Initially, uniform follicular epithelial hyperplasia (diffuse goiter) is present, with an increase in thyroid mass. As the disorder persists, the thyroid architecture loses uniformity, with the development of areas of involution and fibrosis interspersed with areas of focal hyperplasia. This process results in multiple nodules (multinodular goiter). On nuclear scintigraphy, some nodules are hot, with high isotope uptake (autonomous) or cold, with low isotope uptake, compared with the normal thyroid tissue (as demonstrated in the images below). The development of nodules correlates with the development of functional autonomy and reduction in thyroidstimulating hormone (TSH) levels. Clinically, the natural history of a nontoxic goiter is growth, nodule production, and functional autonomy (resulting in thyrotoxicosis in a minority of patients).

Causes
The exact causes of nontoxic goiter are not known. In general, goiters may be caused by too much or too little thyroid hormones. There is often normal thyroid function with a nontoxic goiter. Some possible causes of nontoxic goiter include: Heredity (family history of goiters) Regular use of medications such as lithium , propylthiouracil , phenylbutazone, or aminoglutethimide Regular intake of substances (goitrogens) that inhibit production of thyroid hormonecommon goitrogens include foods such as cabbage, turnips, brussel sprouts, seaweed, and millet Iodine deficiencyIodine deficiency is very rare in the US and other developed countries, due to the use of iodized table salt; this is a primary cause of goiter in other parts of the world, particularly in mountainous areas, or areas that experience heavy rainfall or flooding

Risk Factors
The following factors increase your chance of developing nontoxic goiter:

Sex: female (nontoxic goiter is more common in women than men) Age: over 40 year: Family history of goiter History of radiation therapy to head or neck, especially during childhood

Symptoms
Nontoxic goiters usually do not have noticeable symptoms. If you experience any of these, do not assume it is due to this condition. These may be caused by other, less serious health conditions. If these symptoms persist, see your doctor.

Swelling on the neck Breathing difficulties, coughing, or wheezing with large goiter Difficulty swallowing with large goiter Feeling of pressure on the neck Hoarseness

Diagnosis
Your doctor will ask about your symptoms and medical history. A physical exam will be done. Your doctor may recommend a specialist. An endocrinologist focuses on hormone related issues. Tests may include the following: Examination of the neckto assess any thyroid enlargement Ultrasound a test that uses sound waves to identify nodules of the neck and thyroid Blood teststo assess levels of thyroid hormones (eg, thyroid stimulating hormone); thyroid autoantibodies tests may also be done Thyroid scan (scintigraphy)a picture of your thyroid gland taken after you have been given a shot or drink of a radioisotope to show how your thyroid is functioning and exclude thyroid cancer Fine needle aspiration biopsy a tissue sample is taken with a small needle to determine if it is benign or malignant (cancer); 50%-60% are noncancerous Barium swallow a test to determine if the enlarged goiter is compressing the esophagus, thus causing swallowing difficulty X-ray of neck and chest for large goitersto see if the trachea is compressed

Treatment
Nontoxic goiters usually grow very slowly. They may not cause any symptoms. In this case they do not need treatment. Treatment may be needed if the goiter grows rapidly, affects your neck or obstructs your breathing .

If a nontoxic goiter progresses to the nodular stage, and the nodule is found to be cancerous, you will need treatment. Talk with your doctor about the best plan for you. Treatment options include the following: Hormone Suppression Therapy Thyroid hormone medication is used to suppress secretion of thyrotropin (TSH). TSH is the thyroid-stimulating hormone that causes growth. This therapy is most effective for early stage goiters that have grown due to impaired hormone production. It is less effective for goiters that have progressed to the nodular stage. Radioactive Iodine Radioactive iodine treatment is used to reduce the size of large goiter. It is used in the elderly when surgical treatment is not an option. Thyroidectomy A surgery to remove a portion or all of the thyroid gland. It is the treatment of choice if the goiter is so large to cause difficulty in breathing or swallowing.

Prevention
Be sure that your diet contains enough iodine.

Bibliography

http://emedicine.medscape.com/article/120392-overview#showall http://en.wikipedia.org/wiki/Goiter http://www.upmc.com/healthatoz/pages/HealthLibrary.aspx?chunkiid=96739