December 2007

Q: I am 87 years old and was told I have an enlarged thyroid (goiter). It is pressing on my voice box; I am hoarse all the time and short of breath. Are all enlarged thyroids just goiters? Is it possible it could be cancer? What causes this condition? Is surgery the only option or is it best to leave it alone? I have a heart problem as well as chronic back pain. Any information or advice you can provide will be appreciated.

A: The term “goiter” simply refers to any abnormal enlargement of the thyroid gland. A goiter can occur in a gland that is producing too much hormone (hyperthyroidism), too little hormone (hypothyroidism), or the correct amount of hormone (euthyroidism).

Causes of goiter
Iodine deficiency is the most common cause of goiter worldwide, but this has been almost entirely eliminated in the United States since the addition of iodide to salt in the 1920s. Goiter can sometimes be caused by thyroid nodules. A nodule is a lump within the gland. Goiters and thyroid nodules increase in frequency as we age. The vast majority (92-95%) of thyroid nodules are non-cancerous. Goiter can also be caused by two autoimmune thyroid diseases, Hashimoto’s thyroiditis and Graves’ disease.

Getting a diagnosis
The first step in evaluating goiter is to have thyroid function blood tests to determine if your thyroid is underactive or overactive. Other diagnostic tests may include a radioactive iodine scan, thyroid ultrasound, or a fine needle aspiration biopsy of thyroid nodules.

Treating goiter
If you are hypothyroid, you will be given thyroid hormone supplementation as a daily pill. If the thyroid is overactive, treatment options include antithyroid medication, radioactive iodine treatment, or surgery.

If there are normal levels of thyroid hormone–and this is usually the case with goiters— treatment will usually depend on the size of the gland. If the gland is not pressing on any other structures in the neck, usually no treatment is needed. Symptoms of hoarseness and shortness of breath can be caused by pressure from a goiter on structures in the neck, including the windpipe and the nerves that control the voice. In this case, the usual recommended treatment is surgery.

Age alone doesn’t prohibit performing surgery, but the decision to have surgery requires careful consideration of other medical problems and the surgical risk. In patients in whom surgery would be risky, treatment with radioactive iodine is sometimes used to decrease the goiter size and it can be reasonably effective.

Reprinted from The Saturday Evening Post magazine, © 2007 SEPS

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