Goiter Workup

Author: James R Mulinda, MD, FACP, FACE; Chief Editor: George T Griffing, MD more...

Updated: May 19, 2011

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Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
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References

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.

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 roentgenography.

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.

MRI

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, as shown below. 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. See the image below.

Thyroid nuclear scan of a patient with a euthyroid goiter showing different projections.

Other

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.

Fine-needle aspiration biopsy is used for cytologic diagnosis.^[7]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.

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Contributor Information and Disclosures

Author

James R Mulinda, MD, FACP, FACE Consulting Staff, Department of Endocrinology, Endocrinology Associates, Inc

James R Mulinda, MD, FACP, FACE is a member of the following medical societies: American College of Clinical Endocrinologists and American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Steven R Gambert, MD, MACP Chairman, Department of Medicine, Physician-in-Chief, Sinai Hospital of Baltimore; Professor of Medicine, Program Director, Internal Medicine Program, Johns Hopkins University School of Medicine

Steven R Gambert, MD, MACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American Geriatrics Society, Association of Professors of Medicine, Endocrine Society, and Gerontological Society of America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Kent Wehmeier, MD Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine

Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, and International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Mark Cooper, MBBS, PhD, FRACP Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

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].
Rasmussen LB, Schomburg L, Kohrle J, et al. Selenium status, thyroid volume, and multiple nodule formation in an area with mild iodine deficiency. Eur J Endocrinol. Apr 2011;164(4):585-90. [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. 6^th ed. Mosby-Year Book; 1997:101-112.
Becker KL, Bilezikian JP, Bremner WJ. Nontoxic goiter. In: Principles and Practice of Endocrinology and Metabolism. 2^nd 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. 7^th 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. 8^th ed. Harcourt Brace & Co; 1992:463-465.

Patient with a goiter. Prominent side-view outline.