Thyroid Goiter and Thyroid Nodules

thyroid check

Do you have an enlarged thyroid? If your doctor has diagnosed you as having thyroid nodules, a thyroid lump, or an enlargement of the thyroid, known as goiter, you'll want to learn more about the signs, symptoms, tests, and treatments for these thyroid conditions.

What Is a Goiter?

The term goiter refers to any situation where your thyroid gland has become abnormally enlarged. A normal thyroid gland weighs about an ounce and is not visible externally. But with goiter, the thyroid enlarges enough so that the change is detectable by ultrasound or x- rays, and in some cases, your neck may show a visible lump or bulge.

Goiter can occur in a number of situations:

  • When your thyroid gland is producing too much thyroid hormone (hyperthyroidism)
  • When your thyroid is not producing enough thyroid hormone (hypothyroidism)
  • When you have an autoimmune thyroid disease—Graves' disease or Hashimoto's disease—that is causing an inflammatory reaction in your thyroid
  • When you have a single or multiple thyroid nodules
  • When you have underlying thyroid cancer
  • When you are iodine deficient

Common Signs & Symptoms of Goiter

Signs of goiter include:

  • Neck enlargement
  • Visible lump or swelling in the neck area

Note, however, that some situations of goiter may not be externally visible, and only detected by imaging tests.

Symptoms of a goiter include:

  • Tenderness to the touch
  • A feeling of fullness in the neck
  • A feeling of pressure on your windpipe or your esophagus
  • Difficulty swallowing, or a feeling that food is stuck in your throat
  • Shortness of breath or difficulty breathing, especially at night
  • Coughing
  • Hoarseness
  • Discomfort with turtlenecks, ties, and scarves

In some cases, you may have hypothyroidism or hyperthyroidism symptoms accompanying the goiter.

In some cases, a goiter may cause no symptoms.

Tests and Procedures to Diagnose a Goiter

Detection of goiter is most often done visually or manually during a clinical examination by your physician. In some cases, a goiter may be detected during imaging tests.

When goiter is detected, the next step is to evaluate the cause and determine what thyroid abnormality has triggered the enlargement. This evaluation will typically include key thyroid tests, including the TSH, Free T4, Free T3, and thyroid antibodies tests to look for Hashimoto's (thyroid peroxidase antibodies/TPO) and Graves' disease (thyroid stimulating immunoglobulins/TSI). Iodine levels may also be evaluated to check for iodine deficiency.

Your doctor may also order imaging tests such as ultrasound, MRI, CT scan, or a thyroid uptake scan, to evaluate the extent of goiter, to see whether it is affecting your breathing or swallowing, and determine if you have nodules.

Goiter Treatments

Treatment for goiter depends on the cause and the symptoms.

  • If you have a small goiter with no symptoms and no other underlying thyroid disease, your doctor may recommend periodic monitoring with no treatment.
  • If your goiter is due to an iodine deficiency, you will be given iodine supplementation. This will usually slow or stop growth, and may reduce the size of the goiter somewhat, but often not completely.
  • If your goiter is associated with hypothyroidism, treatment with thyroid hormone replacement drugs may slow or stop the growth of the gland. It may not, however, shrink your goiter.
  • If your goiter is associated with hyperthyroidism due to Graves' disease, treatment—including radioactive iodine, or antithyroid drugs—may slow or stop the gland's enlargement, and may shrink the goiter.
  • If your goiter continues to grow while on thyroid treatment, symptoms are debilitating, or the goiter is cosmetically unsightly, your doctors will likely recommend surgery, known as a thyroidectomy.

What Are Thyroid Nodules?

Thyroid nodules are swellings or lumps in your thyroid gland. Nodules can be solid, or liquid-filled cysts. Thyroid nodules are extremely common, and it's estimated that half the population has at least one nodule, although most are not aware of it. Thyroid nodules are also more common as you age, and it's estimated that by age 70 as many as 70 percent of people have at least one thyroid nodule.

Nodules can occur for a number of reasons:

  • Thyroid cancer. This is the least common cause of thyroid nodules, and approximately 95 percent of all thyroid nodules are non-cancerous.
  • Autoimmune thyroid conditions, such as Hashimoto's and Graves' disease, that cause inflammation of the gland and result in nodules.
  • Overgrowth of your normal thyroid tissue. This is known as a thyroid adenoma, and is usually not cancerous or considered serious unless the nodule is causing symptoms due to its size.
  • Iodine deficiency. This can trigger nodule development, along with goiter.
  • Multinodular goiter, also known as a toxic adenoma, where you have a number of nodules. Typically, these nodules produce thyroid hormone and can result in hyperthyroidism.

Common Signs & Symptoms of Thyroid Nodules

In some cases, if you have a very large nodule, or it is close to the surface of your skin, it may be visible externally or able to be felt by your practitioner's manual evaluation. Many nodules, however, are not visible or palpable, and can only be detected by imaging tests.

In many cases, nodules cause no obvious symptoms. But when thyroid nodules do cause symptoms, some common ones include:

  • Palpitations
  • Insomnia
  • Weight loss or weight gain
  • Anxiety
  • Tremors
  • Fatigue
  • Depression
  • Sensitivity in the neck
  • Difficulty swallowing
  • A feeling of fullness or tenderness in the neck
  • Hoarseness

Tests and Procedures to Diagnose Thyroid Nodules

When a thyroid nodule is detected, your physician will be evaluating several key questions:

  • Is the nodule making too much thyroid hormone and causing hyperthyroidism?
  • Is the nodule impairing the thyroid's ability to produce enough thyroid hormone and causing hypothyroidism?
  • Is your nodule cancerous?
  • Is your nodule affecting your breathing or swallowing?

The first step in evaluation is typically a panel of blood tests, including TSH, Free T4, Free T3, and antibodies tests for Hashimoto's and Graves' disease. This can help determine if the nodule is causing hyperthyroidism or hypothyroidism.

The next step is typically thyroid imaging tests, which may include ultrasound, MRI, CT scan, or a radioactive iodine uptake scan. They are often performed to evaluate the size and characteristics of the nodule and identify suspicious characteristics that would warrant further investigation. Some of the imaging test characteristics that are considered suspicious include:

  • A solitary nodule (versus multiple nodules)
  • Presence of microcalcification in the nodule
  • A size greater than 2 cm
  • Solid composition of the nodule
  • "Cold" properties on the uptake test, meaning that the nodule does not absorb iodine or produce thyroid hormone
  • Rapid growth of a nodule

If a nodule is deemed suspicious, the next step is typically a fine needle aspiration (FNA) biopsy. In this test, a needle is inserted into the nodule—usually guided by ultrasound—to withdraw a sample for pathological analysis. One or more samples may be needed for thorough testing. Typically, FNAs are done by endocrinologists, cytopathologists, or surgeons. The cells are studied and assessed by a cytopathologist. Many FNAs are performed in a doctor's office, although some might be done as an outpatient procedure in a hospital or surgery center.

It is important that the practitioner performing your FNA has extensive experience, in order to make sure the procedure produces the best possible samples. A percentage of FNA biopsy results are considered non-diagnostic, meaning they cannot be used at all and must be redone; an outcome more likely to happen when less experienced practitioners do the sampling. The main risk of thyroid FNA is bleeding or hemorrhage. But with an experienced practitioner, that risk is small, and thyroid FNA is generally considered safe, almost never resulting in any complications.

One of the most frustrating challenges is when FNA results come back as "inconclusive" or "indeterminate." In this case, the pathology assessment cannot rule out cancer. The conventional next step for this situation is thyroidectomy—a surgery to remove the thyroid, which is then evaluated to conclusively diagnose or rule out thyroid cancer.

When no thyroid cancer is discovered, which happens in the majority of cases, the patient needs to live with lifelong hypothyroid, after an otherwise unnecessary thyroidectomy.

It's estimated that almost a half-million FNA biopsies are conducted in the United States each year, and up to 30 percent of those come back as indeterminate, or inconclusive. Only 20 to 30 percent of inconclusive nodules are found to be malignant.

You should, therefore, be aware of a test called the Afirma Thyroid FNA Analysis, which, if conducted at the time of the initial biopsy, eliminates almost all inconclusive and indeterminate FNA results. Note that you would need to confirm that your doctor is using this system before your FNA is scheduled, or find a doctor who works with this particular testing.

Thyroid Nodule Treatments

If a nodule is found to be cancerous, the next step is surgical removal and subsequent treatment based on the type and stage of cancer diagnosed.

If you have nodules that are cosmetically unsightly, or they are impairing your ability to swallow or breathe, surgery is often recommended.

If a benign nodule is not accompanied by any hyperthyroidism or hypothyroidism, it will typically be monitored periodically by ultrasound and examination by your physician.

Typically, for a benign nodule that is causing hypothyroidism, the treatment is to prescribe thyroid hormone replacement medication. This may help shrink the nodule somewhat or prevent it from growing. If the nodule continues to grow, your doctor may biopsy it again, recommend surgical removal, or recommend a treatment such as percutaneous ethanol injection (PEI) into the nodule, which may help to shrink the nodule.

If a benign nodule or toxic adenoma is accompanied by hyperthyroidism, the treatment is typically antithyroid medication, or in some cases, radioactive iodine ablation or surgery, depending on the extent of the hyperthyroidism, your response to medications, and other factors determined by your physician.

A Word From Verywell

Remember that even though the risk of thyroid cancer is very small, all nodules should be evaluated by a practitioner, to rule out the small risk that they are cancerous.

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View Article Sources
  • Braverman L, Cooper D. Werner & Ingbar's The Thyroid, 10th Edition. WLL/Wolters Kluwer; 2012.
  • Haugen B. et. al. "2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer / The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer." Thyroid. Volume 26, Number 1, 2016. DOI: 10.1089/thy.2015.0020