| Goitre | |
|---|---|
| Classification and external resources | |
| ICD-10 | E01-E05 |
| ICD-9 | 240.9 |
| DiseasesDB | 5332 |
| MedlinePlus | 001178 |
| MeSH | D006042 |
A goitre or goiter (Latin gutteria, struma), is a swelling in the thyroid gland,[1] which can lead to a swelling of the neck or larynx (voice box). Goitre is a term that refers to an elargement of the thyroid and can be associated with a thyroid gland that is functioning properly or not.
Worldwide, over 90% cases of goitre are caused by iodine deficiency.[2]
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Goitre associated with hypothyroidism or hyperthyroidism may be present with symptoms of the underlying disorder, although the symptoms are often unspecific and hard to diagnose.
Goitre not associated with hormonal abnormalities will not cause any symptoms aside from the presence of anterior neck mass. However, for particularly large masses, compression of the local structures may result in difficulty in breathing or swallowing. In those presenting with these symptoms, malignancy must be considered.
Toxic goitres will present with symptoms of thyrotoxicosis such as palpitations, hyperactivity, weight loss despite increased appetite, and heat intolerance.
Regarding morphology, goitres may be classified either as the growth pattern or as the size of the growth:
Worldwide, the most common cause for goitre is iodine deficiency, usually seen in countries that do not use iodized salt. Selenium deficiency is also considered a contributing factor. In countries that use iodized salt, Hashimoto's thyroiditis is the most common cause.[3]
| Cause | Pathophysiology | Resultant thyroid activity | Growth pattern | Treatment | Incidence and prevalence | Prognosis |
|---|---|---|---|---|---|---|
| Iodine deficiency | Hyperplasia of thyroid to compensate for decreased efficacy | Can cause hypothyroidism | Diffuse | Iodine | Constitutes over 90% cases of goitre worldwide[2] | Increased size of thyroid may be permanent if untreated for around five years |
| Congenital hypothyroidism | Inborn errors of thyroid hormone synthesis | Hypothyroidism | ||||
| Goitrogen ingestion | ||||||
| Adverse drug reactions | ||||||
| Hashimoto's thyroiditis | Autoimmune disease in which the thyroid gland is gradually destroyed | Hypothyroidism | Diffuse and lobulated[4] | Thyroid hormone replacement | Prevalence: 1 to 1.5 in a 1000 | Remission with treatment |
| Pituitary disease | Hypersecretion of thyroid stimulating hormone, almost always by a pituitary adenoma[5] | Diffuse | Pituitary surgery | Very rare[5] | ||
| Graves' disease - also called Basedow syndrome | Autoantibodies (TSHR-Ab) that activate the TSH-receptor (TSHR) | Hyperthyroidism | Diffuse | Antithyroid agents, radioiodine, surgery | 1 to 2 cases per 1,000 population per year | Remission with treatment, but still lower quality of life for 14 to 21 years after treatment, with lower mood and lower vitality, regardless of the choice of treatment[6] |
| Thyroiditis | Acute or chronic inflammation | Can be hyperthyroidism initially, but progress to hypothyroidism | ||||
| Thyroid cancer | Usually uninodular | Overall relative 5-year survival rate for of 85% for females and 74% for males[7] | ||||
| Benign thyroid neoplasms | Usually hyperthyroidism | Usually uninodular | Mostly harmless | |||
| Thyroid hormone insensitivity | Secretional hyperthyroidism, Symptomatical hypothyroidism |
Diffuse |
Goitre is more common among women, but this includes the many types of goitre caused by autoimmune problems, and not only those caused by simple lack of iodine.
Some researchers [9] showed a correlation between Iodine-deficient goitre and gastric cancer, and reported in goitrous territories a decrease of the incidence of goitre and of stomach cancer after implementation of iodine-prophylaxis.[10] The proposed mechanism of action is that iodide ion (I-) can function in thyroid gland and in gastric mucosa as an antioxidant [11] reducing species that can detoxify poisonous reactive oxygen species, such as hydrogen peroxide.
Chinese physicians of the Tang Dynasty (618–907) were the first to successfully treat patients with goitre by using the iodine-rich thyroid gland of animals such as sheep and pigs—in raw, pill, or powdered form, in 1889.[12] This was outlined in Zhen Quan's (d. 643 AD) book, as well as several others.[13] One Chinese book, The Pharmacopoeia of the Heavenly Husbandman, asserted that iodine-rich sargassum was used to treat goitre patients by the 1st century BC, but this book was written much later.[14]
In the 12th century, Zayn al-Din al-Jurjani, a Persian physician, provided the first description of Graves' disease after noting the association of goitre and exophthalmos in his Thesaurus of the Shah of Khwarazm, the major medical dictionary of its time.[15][16] Al-Jurjani also established an association between goitre and palpitation.[17] The disease was later named after Irish doctor Robert James Graves, who described a case of goitre with exophthalmos in 1835. The German Karl Adolph von Basedow also independently reported the same constellation of symptoms in 1840, while earlier reports of the disease were also published by the Italians Giuseppe Flajani and Antonio Giuseppe Testa, in 1802 and 1810 respectively,[18] and by the English physician Caleb Hillier Parry (a friend of Edward Jenner) in the late 18th century.[19]
Paracelsus (1493–1541) was the first person to propose a relationship between goitre and minerals (particularly lead) in drinking water.[20] Iodine was later discovered by Bernard Courtois in 1811 from seaweed ash.
Goitre was previously common in many areas that were deficient in iodine in the soil. For example, in the English Midlands, the condition was known as Derbyshire Neck. In the United States, goitre was found in the Great Lakes, Midwest, and Intermountain regions. The condition now is practically absent in affluent nations, where table salt is supplemented with iodine. However, it is still prevalent in India, China[21] Central Asia and Central Africa.
Goitre had been prevalent in the alpine countries for a long time. Switzerland reduced the condition by introducing iodised salt in 1922. The Bavarian tracht in the Miesbach and Salzburg regions, which appeared in the 19th century, includes a choker, dubbed Kropfband (struma band) which was used to hide either the goitre or the remnants of goitre surgery.[22]
The coat of arms and crest of Die Kröpfner, of Tyrol showed a man "afflicted with a large goitre," an apparent pun on the German for the word.[29]
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