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  • • May be a diffuse or a multinodular goiter

    • May be physiologic or pathophysiologic

    • -Physiologic occurs during puberty, menses, or pregnancy

      -Pathophysiologic is due to iodine-deficiency, congenital defect in thyroid hormone production, or goitrogenic foods or drugs

    • Generally assumed to be compensatory response to inadequate thyroid hormone production

    • Thyroid growth immunoglobulins may also be important

    • Food goitrogens include isothiocyanate and goitrin (in milk products)

    • Drugs implicated as goitrogens include:

    • -Lithium

      -p-Aminosalicylic acid

      -Aminoglutethimide

      -Sulfonamides

      -Phenylbutazone

    • Congenital determined failures in thyroid hormone metabolism include iodine transport defects, abnormal secretion of iodoproteins, and thyroid hormone resistance syndromes

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Epidemiology

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  • • Prevalence of about 5%; increases with age and in women

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Symptoms and Signs

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  • • Neck mass

    • Inspiratory stridor

    • Dyspnea

    • Dysphagia

    • Symmetrically enlarged thyroid with smooth surface, or enlarged thyroid with multiple nodules

    • Enlargement and prominence of the large veins of the neck and upper thorax

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Laboratory Findings

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  • • Thyroid function tests usually normal

    • Thyroid-stimulating hormone (TSH) may be suppressed slightly, and radioiodine uptake increased

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Imaging Findings

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  • • US reveals size and extent of goiter; can define focal nodules

    • CT or MRI can define retrosternal or intrathoracic extension but are not considered as primary diagnostic tools

    • Thyroid scintigraphy can confirm extension and functional status of the gland

    • Chest radiograph may demonstrate an anterior mediastinal mass, with or without tracheal deviation, in the setting of a substernal goiter

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  • • As the goiter persists, nodules can develop

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Rule Out

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  • • Thyroid malignancy or lymphoma

    • Acute suppurative thyroiditis

    • Silent thyroiditis

    • Subacute thyroiditis

    • Reidel thyroiditis

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  • • Complete history and physical exam

    • Thyroid function tests

    • Thyroid US for cervical goiter

    • CT scan of neck and chest for substernal extension

    • Fine-needle aspiration biopsy of any concerning nodule

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  • • Goiter usually responds favorably to thyroid hormone administration

    • Multinodular goiter can be treated with operative removal, thyroid hormone administration, or radioactive iodine therapy

    • Operative candidates with tracheal compression or deviation should undergo awake, fiberoptic intubation

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Surgery

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Indications

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  • • Relief of local compressive symptoms

    • Diagnostic to rule out cancer in areas of hardness or rapid growth

    • Proven malignancy

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Medications

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  • • Suppressive thyroxine (T4)

    • Radioactive iodine 131

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Treatment Monitoring

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  • • Long-term suppressive/replacement thyroid hormone therapy

    • Monitor TSH and T4

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Prevention

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  • • Long-term administration in diet (to prevent iodine-deficiency goiter)

    • Limit intake of natural or pharmacologic goitrogens

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References

White ML. Doherty GM. Gauger PG. Evidence-based surgical management of substernal goiter. World Journal of Surgery. 2008, 32(7):1285-300....

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