Goitre refers to an enlarged thyroid gland. Patients with a normal functioning thyroid gland (euthyroidism), thyroid deficiency (hypothyroidism) or thyroid hormone surplus (hyperthyroidism) can all present with goitre.
The history gained from a patient will determine the subsequent direction of management. The history should be taken in a systematic approach – focusing on the overall symptoms of common thyroid pathologies. Questions like; have you had a sore throat? Been feeling hot? Pain and swelling of your neck? Do you get cold easily or can you rarely cool down? Have you been feeling tired? Have you been feeling sad? For the parent, it is important to ask questions about their family history, any previous medical conditions, pre, during and post birth history, developmental history, vaccinations, medications, home and social life and whether the parents have noted any changes in their child. Typical features of hypothyroidism include weight gain, reduced growth velocity, fatigue, constipation, dry skin and course hair. Conversely features of hyperthyroidism are hyperactivity/irritability, poor concentration, heat intolerance, weight loss, diarrhoea, tachycardia, and muscle weakness.
There are a number of differentials for goitres:
- Autoimmune thyroid disease (Grave’s Disease – the most common cause of goitre in children)
- Chronic thyroiditis (Hashimoto’s thyroiditis)
- Colloid (simple) goitre
- Drug exposure (e.g. lithium)
- Anatomical abnormalities (e.g. thyroglossal duct cyst)
- Nodular goitre, solitary nodule (e.g. adenoma, carcinoma)
Assessing for the presence of a goitre is an important component of the thyroid examination. The examination begins with assessing the appearance of the patient, for example patients with hypothyroidism will often appear lethargic whereas those with hyperthyroidism will appear anxious and overactive.
The examination then moves onto an inspection of the hands; looking for palmar erythema, onycholysis and thyroid acropachy. Whilst here it is a good opportunity to look for tremor (get the patient to outstretch their hands and place a piece of paper on them, looking for a flutter of the paper) and take the radial pulse – observing rate and rhythm.
Then move to the face, with particular attention to the eyes, looking for any exophthalmos, lid retraction and eye inflammation. Get the patient to follow your finger in a ‘H’ shape, assessing for diplopia and restricted eye movements. Also examine the face for dryness and lack of sweating.
Now the inspection of the thyroid gland. Get the patient to swallow a glass of water and watch the thyroid as the water passes – a thyroid swelling should move up with swallowing. Ask the patient to poke their tongue out to assess for a thyroglossal cyst a thyroid lump should not move.
Stand behind the patient and palpate the two lobes of the thyroid and the isthmus. In this same position, palpate the lymph nodes – submental, submandibular, preauricular, post-aurical, superficial cervical, deep cervical, posterior cervical and supraclavicular.
The clinical picture and the cause will greatly determine the treatment prescribed for goitre. For hypothyroidism, levothyroxine is usually required to replicate normal thyroid function. Iodine deficiency is the commonest cause of hypothyroidism worldwide, and supplementation may be needed in iodine deficient regions or in pregnancy, although in developed countries this can often be achieved through a balanced diet i.e. fortified bread.
For hyperthyroidism, medical management is used in the first instance, inducing thyroxine suppression through drugs such as propylthiouracil or carbimazole. These are commonly used in thyrotoxicosis and Graves’ disease. Radioactive iodine, ablation and surgery are other management options. Surgery is considered depending on the presentation – at times, treatment resistant thyroid disease requires surgery, but unlikely in a child. A large goitre that has not responded to other treatments and is affecting breathing or swallowing may require thyroidectomy.