eMedicine Specialties > Endocrinology > Thyroid
Goiter: Differential Diagnoses & Workup
Updated: Aug 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
| Lipomas | Thyroid, Papillary Carcinoma |
| Thyroid Lymphoma | Thyroiditis, Subacute |
| Thyroid Nodule | |
| Thyroid, Anaplastic Carcinoma | |
| Thyroid, Medullary Carcinoma |
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
Workup
Laboratory Studies
- Initial screening should include TSH. Given the sensitive third-generation assays in the absence of symptoms of hyper or hypothyroidism further testing is not required. An assessment of free thyroxine index or direct measurement of free thyroxine would be the next step in the evaluation.
- Further laboratory testing is based on presentation and results of screening studies and may include thyroid antibodies (antithyroid peroxidase formerly the antimicrosomal antibodies and antithyroglobulin), thyroglobulin, sedimentation rate and calcitonin in an individual at high risk for medullary carcinoma of the thyroid.
Imaging Studies
- Ultrasonography
- Establish and follow goiter size, consistency, and nodularity.4
- Localize nodules for ultrasonographically guided biopsy.
- Roentgenography
- Roentgenography is used to assess extent of a goiter and presence of calcification. Ultrasonography has replaced this modality.
- Roentgenography is used to visualize calcifications within a goiter and regional lymph glands.
- Computed tomography (CT) scanning
- CT scanning is more precise than radiography.
- CT scanning can be used to delineate size and goiter extent. Due to the superficial placement of the thyroid gland, ultrasonography is more useful in following size. CT scanning does a much better job of determining the effect of the thyroid gland on nearby structures. It also may be useful in the follow-up of patients with thyroid cancer that shows evidence of recurrence.
- CT scanning can be used to guide biopsy of the thyroid.
- Magnetic resonance imaging has the same indications as CT scanning (see above).
- Radionuclide uptake and radionuclide scanning are used to assess thyroid function and anatomy in hyperthyroidism (see image below and Image 1). Additionally, thyroid scanning may be useful in the patient with neck or superior mediastinal masses. Radionuclide scanning allows determination of the function of a nodule. Function of a thyroid nodule has value both diagnostically and therapeutically.
Thyroid nuclear scan of a patient with a euthyroid goiter showing different projections.
- Barium swallow is used to assess esophageal obstruction.
- Spirometry: The flow-volume loop is useful in determining the functional significance of compressive goiters.
- Perchlorate discharge test is used in individuals with inborn errors of thyroid hormone synthesis. It is used rarely today to determine the ability to trap and organify iodine.
Procedures
- Fine-needle aspiration biopsy is used for cytologic diagnosis.6 Fine-needle aspiration of the thyroid is used to determine the cause of an enlarged gland. In general, the procedure is not used in the workup of autonomously functioning nodules. The procedure has little morbidity and can be tailored to the situation.
- Core biopsy, or large-needle biopsy, of the thyroid uses a larger gauge needle providing a fragment of tissue. This procedure also carries with it a higher morbidity. Core biopsy has the advantage of more complete sampling.
- Partial thyroidectomy may be used as a first-line procedure for patients with a high probability of cancer. It is reserved mostly if the result of a fine-needle aspiration is suspicious or if the patient/physician prefers it.
- Total thyroidectomy is performed for malignant goiters.
Histologic Findings
Simple nontoxic goiters show hyperplasia, colloid accumulation, and nodularity. Nodular hyperplasia is commonly seen in multinodular goiter. Cytologic findings include benign appearing follicular cells, abundant colloid, macrophages, and, sometimes, Hürthle cells. Inflammatory disorders of the thyroid, such as chronic lymphocytic (Hashimoto) thyroiditis, contain a mixed population of lymphocytes mixed with benign appearing follicular cells. Malignant nodules may be follicular cell in origin, ie, papillary (most common), follicular, Hürthle cell, or anaplastic. They also may be from parafollicular cells, medullary carcinoma or lymphoma, or other categories.
More on Goiter |
| Overview: Goiter |
 Differential Diagnoses & Workup: Goiter |
| Treatment & Medication: Goiter |
| Follow-up: Goiter |
| Multimedia: Goiter |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Triggiani V, Tafaro E, Giagulli VA, et al. Role of iodine, selenium and other micronutrients in thyroid function and disorders. Endocr Metab Immune Disord Drug Targets. Sep 1 2009;[Medline].
Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, et al. The spectrum of thyroid disease in a community: the Wickham survey. Clin Endocrinol (Oxf). Dec 1977;7(6):481-93. [Medline].
Sawin CT, Geller A, Hershman JM, Castelli W, Bacharach P. The aging thyroid. The use of thyroid hormone in older persons. JAMA. May 12 1989;261(18):2653-5. [Medline].
Guth S, Theune U, Aberle J, Galach A, Bamberger CM. Very high prevalence of thyroid nodules detected by high frequency (13 MHz) ultrasound examination. Eur J Clin Invest. Aug 2009;39(8):699-706. [Medline].
Duarte GC, Tomimori EK, de Camargo RY, Catarino RM, Ferreira JE, Knobel M, et al. Excessive iodine intake and ultrasonographic thyroid abnormalities in schoolchildren. J Pediatr Endocrinol Metab. Apr 2009;22(4):327-34. [Medline].
Pinchot SN, Al-Wagih H, Schaefer S, Sippel R, Chen H. Accuracy of fine-needle aspiration biopsy for predicting neoplasm or carcinoma in thyroid nodules 4 cm or larger. Arch Surg. Jul 2009;144(7):649-55. [Medline].
Arda IS, Yildirim S, Demirhan B, Firat S. Fine needle aspiration biopsy of thyroid nodules. Arch Dis Chil. 2001;85(4):313-7. [Medline].
Bardin CW. Endemic goiter. In: Current Therapy in Endocrinology and Metabolism. 6th ed. Mosby-Year Book; 1997:101-112.
Becker KL, Bilezikian JP, Bremner WJ. Nontoxic goiter. In: Principles and Practice of Endocrinology and Metabolism. 2nd ed. Lippincott Williams & Wilkins; 1995:338-345.
Bostanci I, Sarioglu A, Ergin H, Aksit A, Cinbis M, Akalin N. Neonatal goiter caused by expectorant usage. J Pediatr Endocrinol Metab. Sep-Oct 2001;14(8):1161-2. [Medline].
Braverman LE, Utiger RD. Thyroid diseases: nontoxic diffuse and multinodular goiter. In: Werner and Ingbar, eds. The Thyroid: A Fundamental and Clinical Text. 7th ed. Lippincott-Raven; 1996:889-900.
Gross JL. Ultrasonography in management of nodular thyroid disease. Annals of internal medicine. 2001;135(5):383-4. [Medline].
Romanchishen AF, Iakovlev PN. [Special surgical treatment of patients with nodular tumors of the thyroid gland against the background of diffuse toxic goiter]. Vestn Khir Im I I Grek. 2005;164(1):21-4. [Medline].
Sawin CT, Geller A, Wolf PA, et al. Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med. Nov 10 1994;331(19):1249-52. [Medline].
Schumm-Draeger PM. [Every third German has a sick thyroid gland. Nodules and goiter are a challenge that needs to be met]. MMW Fortschr Med. Feb 5 2004;146(6):20. [Medline].
Thompson L. Dyshormonogenetic goiter of the thyroid gland. Ear Nose Throat J. Apr 2005;84(4):200. [Medline].
Vetshev PS, Chilingaridi KE, Bannyi DA, Dmitriev EE. [Repeated surgeries on the thyroid gland in nodular euthyroid goiter]. Khirurgiia (Mosk). 2004;37-40. [Medline].
Wilson JD, Foster DW. The thyroid gland. In: Williams Textbook of Endocrinology. 8th ed. Harcourt Brace & Co; 1992:463-465.
Further Reading
Clinical guidelines:
American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules.
American Association of Clinical Endocrinologists - Medical Specialty Society
Associazione Medici Endocrinologi - Medical Specialty Society. 1996 Jan (revised 2006 Feb). 40 pages. NGC:004869
Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.
American Thyroid Association - Professional Association. 2006 Feb. 34 pages. NGC:005212
Screening for congenital hypothyroidism: U.S. Preventive Services Task Force reaffirmation recommendation statement.
United States Preventive Services Task Force - Independent Expert Panel. 1996 (revised 2008 Mar). 6 pages. NGC:006354
rhTSH, Radioiodine Uptake and Goiter Reduction Following 131I Therapy in Patients With Benign Nontoxic Nodular Goiter
Block-Replacement Therapy During Radioiodine Therapy
Levothyroxine Treatment in Thyroid Benign Nodular Goiter
Keywords
goiter, goiter disease, thyroid disease, thyroid cancer, iodine deficiency, hypothyroidism, hyperthyroidism, thyroid nodules, thyroid gland goiter, nontoxic goiter, toxic goiter, multinodular goiter, endemic goiter, Hashimoto disease, iodine, enlarged thyroid gland, inborn errors of thyroid hormone synthesis, goitrogens, TSH receptor antibodies, pituitary resistance to thyroid hormone, adenomas of hypothalamus, adenomas of pituitary gland, tumors producing human chorionic gonadotropin, autoimmune thyroiditis, Hashimoto disease, swelling in the neck, Graves disease, Hashimoto thyroiditis
Riedel struma, toxic multinodular goiter, subacute thyroiditis, diffuse toxic goiter, toxic adenoma, Plummer disease, chronic lymphocytic thyroiditis, sporadic goiter, congenital goiter, physiologic goiter, Pemberton maneuver, postpartum thyroiditis, Wolff-Chaikoff effect, lithium ingestion, pituitary thyroid hormone resistance, thyroid-stimulating immunoglobulins, thyroid hormone resistance, de Quervain thyroiditis, silent thyroiditis, Riedel thyroiditis, granulomatous disease, thyroid malignancy
