THE ROLE OF MEDICAL

TREATMENT IN GOITER
Agung Pranoto
Division of Endocrinology & Metabolism
Department of Internal Medicine, Airlangga Faculty of Medicine
Dr.Soetomo Hospital

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

INTRODUCTION
Definition: A goiter is an enlarged thyroid
gland, and it may be diffuse or nodular.
A goiter may extend into the retrosternal
space, with or without anterior enlargement.
may cause a variety of compressive
syndromes.

Thyroid function may be normal (nontoxic

goiter), overactive (toxic goiter), or
underactive (hypothyroid goiter).

FREQUENCY
Whickham study United Kingdom: 16% of population
Framingham study (USG): Thyroid nodules
3% men > 60 years
36% women aged 49-58 years

In the United States, most goiters are due to autoimmune

thyroiditis (ie, Hashimoto disease.)
Indonesia:

Gaky 53,8 millions living in iodine deficient area

20 millions Endemic Goiter
290 thousands are cretinsm
9 thousands cretinsm newborns every year

History
Incidentally, as a swelling in the neck discovered
by the patient or on routine physical examination
A finding on imaging studies
Local compression causing dysphagia, dyspnea,
stridor, plethora or hoarseness
Pain due to hemorrhage, inflammation, necrosis,
or malignant transformation
Signs and symptoms of hyperthyroidism or
hypothyroidism
Thyroid cancer with or without metastases

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

CAUSES OF GOITER
Iodine deficiency
Autoimmune thyroiditis: Hashimoto or
postpartum thyroiditis
Excess iodine (Wolff-Chaikoff effect) or lithium
ingestion
Goitrogens
Inborn errors of metabolism
Exposure to radiation
Deposition diseases

CAUSES OF GOITER
Silent thyroiditis
Riedel thyroiditis
Infectious agents
Acute suppurative: bacterial
Chronic: mycobacteria, fungal, and parasitic

Granulomatous disease
Thyroid malignancy

CAUSES OF GOITER

Stimulation of TSH receptors

TSH from pituitary tumors,
pituitary thyroid hormone resistance,
gonadotropins,
and/or thyroid-stimulating immunoglobulins

TOXIC GOITER
A goiter that is associated with
hyperthyroidism is described as a toxic
goiter.
diffuse toxic goiter (Graves disease),
toxic multinodular goiter,
and toxic adenoma (Plummer disease.)

NON TOXIC GOITER

A goiter without hyperthyroidism or hypothyroidism

diffuse or multinodular,
diffuse often evolves into nodular
Examination may not reveal small or posterior nodules.
chronic lymphocytic thyroiditis (Hashimoto disease),
goiter identified in early Graves disease,
endemic goiter,
sporadic goiter,
congenital goiter,
and physiologic goiter that occurs during puberty.

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

DIFFERENTIAL DIAGNOSIS

Lipomas
Thyroid Lymphoma
Thyroid Nodule
Thyroid, Anaplastic Carcinoma
Thyroid, Medullary Carcinoma
Thyroid,Papillary Carcinoma
Thyroiditis, Subacute

Other Problems to be Considered:

Branchial cleft cyst
Thyroglossal duct cyst
Cystic hygroma
Pseudogoiter
Lymphadenopathy
Carotid artery aneurysm
Parathyroid cyst
Parathyroid adenoma
Sarcoma
Fibroma
Thyroid abscess
Granulomatous disease of the thyroid
Infectious thyroiditis
Thyrotoxicosis

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

Medical Care:
1. Small benign euthyroid goiters do not
require treatment.
2. The effectiveness of thyroid hormone for
benign goiters is controversial.

Medical Care:
3. Large and complicated goiters may
require medical and surgical treatment.
4. Malignant goiters require medical and
surgical treatment.

Medical Care
5. Levothyroxine suppressive therapy
a benign euthyroid goiter
Hashimoto's thyroiditis
6. Monitoring:
TSH in a low
avoid hyperthyroidism,
cardiac arrhythmias, and
osteoporosis.
7. Strategy:

suppressive treatment for a definite time period

indefinite therapy.

Medical Care
Treatment of hypothyroidism or hyperthyroidism
often reduces the size of a goiter.
Thyroid hormone replacement is often required
following surgical and radiation treatment of a
goiter.
radioactive iodine for the therapy of nontoxic
goiter has been disappointing and is
controversial.
Medical therapy of autonomous nodules with
thyroid hormone is not indicated.
Ethanol infusion

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodules
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

THYROID NODULES
The lifetime risk for palpable thyroid nodule 5-10%
5% are malignant, whereas the remainder
benign diagnoses, including colloid nodule,
degenerative cyst, hyperplasia, thyroiditis, or benign
neoplasm
Autonomously functioning thyroid nodules
suppressed TSH levels, whether with overt or
subclinical hyperthyroidism
iodine-131 treatment versus surgical
Medical therapy is not indicated.

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

MEDICAL CARE: IODINE DEFICIENCY

Long-term dietary iodine replacement at levels
recommended by the FDA and WHO may decrease the
size of iodine-deficient goiters in very young children and
pregnant women and is indicated for all patients with
iodine deficiency
Long-standing IDD goiters respond with only small
amounts of shrinkage after iodine supplementation.
Compressive symptoms need specific Tx
(eg, tracheal obstruction, thoracic inlet occlusion, hoarseness).

Correction of an iodine deficiency

Adult, 100-150 mcg/d is sufficient for normal
thyroid function.
SSKI, ie, 35,000-50,000 mcg/drop, is
impractical and potentially dangerous.
iodized salt in their cooking and at the table.
Other alternative food sources include milk,
egg yolks, and saltwater fish.
In developing countries,
iodine drops to well water
or injecting people with iodized oil.

Treatment of nontoxic goiters

caused by iodine deficiency
Exogenous L-thyroxine (L-T4) (decrease goiter size)
not effective in adults and older children.
Supplemental L-T4, for autonomous nodules in the
endemic goiter, may cause thyrotoxicosis.
L-T4 therapy: deleterious effects on cardiac and bone health
bone loss, reduction in bone mineral density, and
osteoporosis
Increased heart rate, cardiac wall thickness, and
contractility: increase the risk of atrial fibrillation, in the
elderly

I-131 (to decrease thyroid volume) in patients with

euthyroid goiters (40-60% volume reduction).
In USA, I-131 for toxic multinodular goiters associated
with hyperthyroidism.

Diet for Iodine: WHO recommendations

adults and adolescents: 150 mcg/d

pregnant or lactating women: 200 mcg/d
children (1-11 years) 90-120 mcg/d
infants < 1 year. 50-90 mcg/d

Diet
Iodine supplementation or levothyroxine may
reduce goiter size
avoidance of goitrogens
Cyanoglucosides
cassava, lima beans, maize, bamboo shoots,
and sweet potatoes
Thioglucosides are natural goitrogens found in
the Cruciferae family of vegetables and weeds
eaten by animals.
Thionamidelike passed to humans via milk ingestion.

Cruciferae family eaten by animals

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care

Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis
(Subacute Thyroiditis)
Thyrotoxicosis

Dr. Hakaru Hashimoto, 1881

Autoimmune phenomena in association with

Hashimoto thyroiditis
Addison disease
Alopecia areata, totalis, and
universalis
Autoimmune gastritis
(pernicious anemia)
Chronic active hepatitis
Idiopathic hypoparathyroidism
Polymyalgia rheumatica and
giant cell arteritis
Primary biliary cirrhosis

Primary ovarian or testicular

failure
Rheumatoid arthritis
Sjgren syndrome
Systemic lupus erythematosus
Systemic sclerosis
(scleroderma)
Type 1 diabetes mellitus
Vitiligo

Medical Care: Hashimoto thyroiditis

(or hypothyroidism of any cause)
DOC is levothyroxine sodium, for life.
Tailor and titrate the dose to meet the individual
patient's requirements.
The goal of therapy: euthyroid state.
The standard dose is 1.6-1.8 mcg/kg lean body
weight per day (patient dependent)
Target Tx: free T4 and TSH levels, biochemically
euthyroid state, with the TSH level in the lower
half of the reference range.

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

Acute (Suppurative) Thyroiditis

CT scan of the neck with contrast showing an

abscess of the left lobe of the thyroid gland

Left thyroid abscess.

Acute (Suppurative) Thyroiditis

Strep., Staph., or Pneumococcus
life threatening infection (abscess) of the thyroid
Treatment is multifaceted:
surgical drainage,
tracheostomy and
antibiotics.

In the rare patient who is clinically thyrotoxic,

large doses of beta-blockers,

saturated iodine solution or
steroids may be beneficial.
Thionamides are not indicated unless the patient has
Graves'

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

The diagnosis of de Quervain thyroiditis.

Prodromal flulike symptoms
pharyngitis,
measles,
mumps, Q fever, or typhoid fever, may occur.

In young patients, de Quervain thyroiditis

may develop following an episode of
Henoch-Schnlein purpura
prodromal symptoms often (-)

The diagnosis of de Quervain thyroiditis.

Local symptoms
Pain over the thyroid area that is gradual or of sudden onset;
that usually involves both lobes (in 30% of cases, it starts on one
side and then migrates contralaterally within a few days); that
radiates to the neck, ear, jaw, throat, or occiput; and is
aggravated by swallowing and head movement
Dysphagia
Hoarseness (uncommon)

Constitutional symptoms (often absent)

Fever
Malaise
Anorexia
Fatigue
Muscle aches

Characteristic Course of de Quervain Thyroiditis

Parameters

Stage 1

Stage 2

Stage 3

Stage 4

Euthyroid

Hypothyroid

Euthyroid
(recovery)

Elevated

Normal

Decreased

Normal

Decreased

Normal

Elevated

Normal

Symptoms Hyperthyroid
T4, T3
TSH

Pathophysiology de Quervain thyroiditis.

A viral infection
coxsackievirus, mumps, measles, adenovirus,
echovirus, and influenza),
but the changes could be attributed equally to
nonspecific anamnestic responses.
Viral inclusion bodies are not observed in
thyroid tissue.

(HLA)-B35 in most ethnic groups

MEDICAL CARE de Quervain thyroiditis.

Pain
NSAIDs such as ibuprofen (800-1200 mg/d) or
naproxen (1-1.5 g/d), or aspirin (2-4 g/d)
Alternatives: prednisone 30-40 mg/d

Management of thyroid dysfunction

initial phase:
propranolol 10-20 mg qid or atenolol 25-50 mg/d

the late phase

levothyroxine 25-100 mcg/d (6 months)

Rare cases
levothyroxine 25-100 mcg/d life long

PERSENTATION OVERVIEW

Introduction
Causes of Goiter
Differential Diagnosis
Medical Care
Thyroid Nodule
Iodine deficiency
thyroiditis: Hashimoto
Acute (Suppurative) Thyroiditis
de Quervain thyroiditis (Subacute Thyroiditis)
Thyrotoxicosis

Medical therapy Thyrotoxicosis

blockade of peripheral effects,
beta-blockers reduce sympathetic hyperactivity
decrease peripheral conversion of T4 to T3.
Guanethidine and reserpine (if beta-blockers are
contraindicated)

inhibition of hormone synthesis (Thioamides)

prevention of peripheral conversion of T4 to T3 (PTU)

blockade of hormone release,

Iodides and lithium work to block release of preformed
thyroid hormone.

Restoration of a clinical euthyroid state may take

up to 8 weeks.

TERIMA KASIH