The term ‘GOITRE’ is used to describe generalized enlargement of the Thyroid gland. The normal thyroid gland is impalpable.
Goitre is best classified as –
1) SIMPLE GOITRE-
a) Diffuse Hyperplastic-
• physiologic,
• endemic,
• sporadic
b) Colloid Goitre
c) Solitary Nodular
d) Multinodular

2) TOXIC GOITRE - a) Diffuse (GRAVES DISEASE )
b) Multinodular
c) Solitary nodular (TOXIC NODULE )

3) NEOPLASTIC GOITRE - a) Benign
b) Malignant

4) INFLAMMATORYGOITRE-a)AutoImmune Thyroiditis
b) Granulomatous Thyroiditis
c) fibrosing Thyroiditis
d) Infective- acute- bacterial or viral
chronic- tubercular or syphilitic
5) OTHER RARE TYPES- AMYLOID GOITRE

SIMPLE GOITRE
It is a simple nontoxic enlargement of the thyroid. It may develop as a result of stimulation of the gland by TSH in response to a chronically low level of circulating thyroid hormones T3 and T4. The various types are-

1) DIFFUSE HYPERPLASTIC (PARENCHYMATOUS)
There is uniform enlargement of the thyroid. The goitre is soft, diffuse and may become large enough to cause discomfort. According to the aetiology this can be further classified in to –
a) PHYSIOLOGICAL GOITRE- It is the result of relative iodine deficiency which occurs during periods of increased demand for thyroid hormones such as puberty and pregnancy. At the time of puberty when the metabolic demands are high and in pregnancy when there is too much stress, the goiter develops physiologically. It generally subsides when the stress is over or it may persist. The gland enlarges due to hyperplasia and hypertrophy.

b) ENDEMIC GOITRE- It occurs especially in endemic areas affecting children and adolescents between the ages of 5 and 20. The most important factor here is the dietary deficiency of Iodine. The normal daily requirement of iodine is about 100- 125 microgram. The dietary sources of iodine include seafish, milk, eggs, water etc. An area is termed endemic for goiter when 10% or more of the population is affected. Important among the well recognized goiter belts of the world are the high mountain ranges of Andes, Alps and Himalayas.

c) SPORADIC GOITRE- The aetiology of this type may be due to the presence of goitrogens in the diet and genetic factors. Goitrogens include the vegetables of brassica family- cabbage, kale, rape, turnips etc. which contain thiocyanate, soyabin, and drugs like PAS and anti thyroid drugs. These interfere with iodide trapping, oxidation of iodide etc. Genetic factors include the deficiency of some enzymes concerned with the production of thyroid hormones.

2) COLLOID GOITRE
It is a late stage of diffuse hyperplasia when TSH stimulation following the physiological stress, has fallen off and when many follicles are inactive and full of colloid. Patients are usually between 20 and 30 years of age. The whole gland becomes enlarged, soft and elastic. Pressure effects like dyspnoea, dysphagia, venous engorgement are rare unless the swelling is enormous.

3) NODULAR GOITRE
Fluctuating levels of TSH may lead to areas of inactive lobules resulting in nodular goiter. When only a single nodule is present it is called as Solitary nodular goiter, its common site being the junction of the isthmus and one lateral lobe. When there are a number of nodules it forms a Multinodular goiter. This type is found 6 times commoner in females than males. The gland assumes asymmetrical shape and its surface becomes smooth and nodular. The consistency varies from soft to hard. Complications like haemorrhage, calcification, secondary thyrotoxicosis and carcinoma may develop.
TOXIC GOITRE

1) DIFFUSE TOXIC GOITRE (GRAVES DISEASE OR EXOPHTHALMIC GOITRE)-
A primary toxic goiter commonly seen in young women. An auto immune disorder, due to thyroid stimulating auto antibodies- LATS in the form of IgG in the serum. The syndrome is characterized by diffuse vascular goiter, loss of weight, intolerance to heat, increased appetite, excessive sweating, palpitation, tachycardia, nervousness, tremor of hands and tongue, insomnia, irritability, hot moist palms, diarrhea, exertional dyspnoea, agitation etc.
Occular manifestations include Exophthalmos (abnormal protrusion of eyeballs), Lid lag, Lid retraction, Von Graef’s sign, Joffroy’s sign, Stelwag’s sign, Moebius sign, Dalrymple’s sign, chemosis, partial or complete ophthalmoplegia, papilloedema and optic atrophy.
Menses becomes scanty, fertility is reduced. In men libido and potency may be altered variebly. Gynaecomastia may develop.
Skin manifestation include pre tibial myxoedema.

2) TOXIC NODULAR GOITRE - (PLUMMER’S DISEASE)
A simple nodular goiter is present for a long time before the hyperthyroidism, usually in middle aged and elderly. Very infrequently associated with eye signs. The syndrome is that of secondary thyrotoxicosis characterized by irregular pulse rate, precordial pain, auricular fibrillation and later heart failure may set in.


3) TOXIC NODULE
Is a follicular TOXIC ADENOMA which autonomously secretes excess thyroid hormones and inhibits endogenous TSH secretion with subsequent atrophy of the rest of the gland. Adenoma is usually greater than 3cm in diameter.

NEOPLASTIC GOITRE
1) BENIGN TUMOURS are rare and present as solitary nodules.
They are of 2 types- a) PAPILLARY ADENOMA
b) FOLLICULAR ADENOMA
2) MALIGNANT TUMOURS- They are of 3 types-
a) CARCINOMA-
• PAPILLARY
• FOLLICULAR
• ANAPLASTIC

b) MEDULLARY CARCINOMA-
These are derived from the parafollicular C-cells. Diarrhoea is an associated symptom.
c) MALIGNANT LYMPHOMA-
The tumour develops from a pre existing Hashimoto’s Thyroiditis.

The growth gradually infiltrates into neighbouring structures causing dyspnoea, dysphagia, hoarseness of voice etc. General weight loss and malaise occur. Metastasis in bone may be the first symptom.

INFLAMMATORY GOITRE

1) AUTOIMMUNE THYROIDITIS (HASHIMOTO’S THYROIDITIS) : Chronic lymphocytic thyroiditis- The condition is associated with high titres of antimicrosomal and antithyroglobulin antibodies. There may be a family history of other autoimmune diseases. The thyroid gets infiltrated with lymphocytes. Most commonly it is associated with hypothyroidism. The thyroid is diffusely enlarged, lobulated, firm or hard in consistency and painless.

2) GRANULOMATOUS THYROIDITIS (DEQUERVAIN’S DISEASE): This is due to a viral infection. In a typical presentation there is pain in the neck, fever, malaise and a firm irregular enlargement of one or both thyroid lobes. ESR is always raised, serum T4 is high normal or slightly raised and I123 uptake of the gland is usually low.

3) FIBROSING THYROIDITIS (RIEDEL’S THYROIDITIS) :
It is a rare chronic inflammatory process involving one or both lobes, even extending to the surrounding tissues. The gland is very hard and is fixed to the trachea. It may occur in association with retroperitoneal and mediastinal fibrosis and is mostly a collagen disease.


DIAGNOSIS
A thyroid swelling always moves upwards on deglutition. On auscultation a systolic bruit may be heard over the goiter in primary toxic goiter. Exophthalmos and other eye signs are diagnostic of Grave’s disease. Indistinct outline of the swelling, hardness and fixity are diagnostic of neoplastic goiter.

DIFFERENTIAL DIAGNOSIS
Mid line swellings of the neck include
• LUDWIG’S ANGINA
• ENLARGED SUBMENTAL LYMPH NODE
• THYROGLOSSAL CYST
• SUB HYOID BURSITIS
• RETROSTERNAL GOITER
• THYMIC SWELLING
• DERMOID CYST
Lateral swellings include
• ENLARGED SUB MANDIBULAR SALIVARY GLAND
• DEEP PLUNGING RANULA
• ANEURYSM OF CAROTID ARTERY
• CAROTID BODY TUMOUR
• BRANCHIAL CYST
• CYSTIC HYGROMA
• PHARYNGEAL POUCH
• SUBCLAVIAN ANEURYSM
• ABERRANT THYROID
• LIPOMA
SPECIAL INVESTIGATIONS

THYROID FUNCTION TESTS
1) SERUM T4- The normal range varies from 4-8 microgram/ dl. The level is usually raised in toxic goiters, low in hypothyroidism.
2) SERUM T3- The normal range varies from 150-250 ng/ dl. Toxic goiters show considerably raised levels.
3) SERUM TSH- The normal level is about 5 microunit/ ml. It is raised in hypothyroidism and almost undetectable in thyrotoxic goiters.
4) SERUM PROTEIN BOUND IODINE- The normal range varies from 3.5-8 microgram/dl.
5) T3 RESIN UPTAKE
6) IODINE 131 UPTAKE TEST- The rate at which the thyroid traps iodine reflects the rate of secretion of thyroid hormones. In hyperthyroidism the rate is increased.
7) THYROID SCAN- Scanning with a tracer dose will show which part of the gland is functioning or which is not (hot or cold). I131 and T99 are used.
8) RADIOGRAPHY- Helps to diagnose the position of trachea, retrosternal goiter etc. In case of carcinoma the bones should be X-rayed for evidence of metastasis. Barium swallow X- ray will indicate pressure effect on oesophagus.
9) FINE NEEDLE ASPIRATION CYTOLOGY-Thyroiditis, colloid nodule, benign and malignant tumours can be diagnosed.
10) MISCELLANEOUS TESTS- These include BMR, serum cholesterol, ECG, measurement of tendon reflexes etc.


TREATMENT
In early stages a simple goiter may regress on administration of thyroxine. Toxic goiters can be treated by anti thyroid drugs. On cosmetic grounds if goiter is unsightly, surgical resection can be done- Sub Total Thyroidectomy. Neoplastic goiters can be treated by Lobectomy or Total Thyroidectomy.

HOMOEOPATHIC MANAGEMENT

IODUM
Simple and exophthalmic goitres. Hard goiter in dark haired persons. Thin and dark complexioned. Scrofulous diathesis. Hypertrophy and induration of glandular tissues except mammae which dwindle and become flabby. Great emaciation. Losing flesh while eating well. Must eat all the time, feels > while eating. Palpitation from least exertion. Tachycardia and tremor. Hot patient.

SPONGIA TOSTA
Exophthalmic goiter. Thyroid gland swollen even with the chin. Swelling and induration of glands. Tubercular diathesis. Palpitation, suffocative paroxysms at night. Dyspnoea as if he had to breath through a sponge. Great dryness of mucus membranes, dry as a horn.

CALCAREA CARB
Simple goiter. Hypothyroidism and Myxoedema. Leucophlegmatic, tendency to obesity in youth. Coldness in general, or of single parts. Takes cold easily. Head sweats profusely wetting the pillow far around. Defective assimilation and imperfect ossification. Scrofulous diathesis.

NATRUM MUR
Primary and secondary thyrotoxic goiters.Anaemic and cachetic, loss of vital fluids. Emaciation, losing flesh while eating well. Fluttering of heart. Heart’s pulsation shakes the whole body. Tongue mapped with red insular patches. Craves salt. Bad effects of grief, anger, mortification. <heat of sun,warmth, 10-11 am, seashore.

THYROIDINUM
Myxoedema, Exophthalmic goiter. Anaemia, emaciation, sweating, muscular weakness. Tachycardia, tremor of face and limbs. Palpitation from least exertion. Anxiety about chest as if constricted.

IODOTHYRINE
Active principle isolated from thyroid gland. Symptoms similar to Thyroidinum.

CALCAREA IODIDE
Thyroid enlargements at the time of puberty. Scrofulous diathesis. Flabby persons subject to colds. Secretions inclined to be profuse and yellow. Adenoids. Enlarged tonsils filled with crypts.

BROMIUM
Hard goiter in fair, light haired, blue eyed persons. Stony hard scrofulous swellings. Indurations. Dryness of mucus membranes. Dyspnoea as if breathing through a sponge. Cold sensation in larynx on inspiration.

CISTUS CANADENSIS
Glandular affections with stony hardness. Malignant diseases of the glands of neck. Spongy feeling in throat. Sensation of coldness. Extremely sensitive to cold. A small dry spot in the throat, must sip water frequently. Swelling of glands of the neck like knotted rope.

LAPIS ALBUS
Indicated in non capsulated goiter when there is a soft doughy feel. Pre ulcerative stage of carcinoma. Glands have a certain elasticity and pliability about them. Fat anaemic persons with ravenous appetite.

CONIUM MACULATUM
Goitre in old maids, old bachelors. Cancerous and scrofulous affections. Glandular indurations of stony hardness. Bad effects of sexual excess. Debility of old people; Complaints caused by a blow or fall. Vertigo when lying down or turning in bed.

PHYTOLACCA
Stony hard painful goiter. Pain flying like electric shocks, rapidly shifting. Emaciation, chlorosis, loss of fat. Patients of a rheumatic diathesis.
Mercurial or syphilitic affections.


CARBO ANIMALIS
Thyroid gland indurated, swollen, painful. Elderly persons with marked venous plethora. Bluish discolouration. Exhausting discharges. Malignant and ichorous conditions.

HYDRASTIS
Goitre at puberty and pregnancy. Debilitated persons, broken down by excessive use of alcohol. Cachetic and malignant dyscratia. Tongue large shows imprint of teeth. Empty all gone sensation in stomach.

ARSENIC IODIDE
Thyroid gland enlarged. Scrofulous diathesis. Profound prostration, emaciation.Thin watery excoriating discharge from anterior and posterior nares. Exfoliation of skin in large scales.

KALI IODIDE
Glandular swellings, indurations. Acts on fibrous and connective tissues. Haemorrhagic diathesis. Hot persons. Profuse acrid watery discharges.

FERRUM IODIDE
Exophthalmic goiter following suppression of menses. Scrofulous diathesis. Tumours.Anaemia. Emaciation.


MERC PROTO IODIDE
Throat affections, glandular swellings. Right sided. Sensation of a lump. Constant inclination to swallow. Tongue coated thick yellow at the base.

MERC BIN IODIDE
Glandular swellings, left sided. Syphilitic, scrofulous persons. Tongue feels stiff at the base, pain on moving.

SILICIA
Scrofulous diathesis. Deficient nutrition, imperfect assimilation. Inflamation, swelling and suppuration of glands. Ailments from suppressed foot sweats, bad effects of vaccination. Every little injury suppurates.

PULSATILLA
Thyroid enlargements at puberty. Delayed menses. Weeping disposition. Mild yielding, consolation >. Pains with chilliness, rapidly shifting. Dry mouth without thirst. > open air.

APIS MEL
Glands indurated, enlarged. Strumous constitutions.Pains burning stinging sore suddenly migrating. Oedema, bag like puffy swelling under the eyes. Right sided. Hot persons. Oversensitive to touch.

GRAPHITIS
Scrofulous diathesis. Women inclined to obesity, at climacteric. Takes cold easily. Every little injury suppurates. Crakes and fissures. Delayed menses, habitual constipation.

SULPHUR
Scrofulous diathesis, persons subject to venous congestion especially of portal system. Lean stoop shouldered. Hot patient. Chronic alcoholism. Burning sensation all over,< heat of bed, night. Empty all gone sensation at 11 am.

FLOURIC ACID
Simple goiters. Complaints of old aged, or prematurely old aged. Increased ability to exercise with out danger. Hot persons. Varicose veins and ulcers. Imndifference. Sexual excitement.

FUCUS VESICULOSUS
Exophthalmic and non toxic goiters. Thyroid enlargements in obese persons. Impaired digestion. Obstinate constipation.

LYCOPUS VERGINICUS
Exophthalmic goiters. Beneficial in toxic goiters, used in the pre operative stages. Lowers the blood pressure, reduces the heart rate.

BADIAGA
Grave’s disease or Basedow’s disease. Glands swollen, indurated. Oversensitive to cold. Syphilitic affections.

PILOCARPIN
Exophthalmic goiters, with increased heart’s action and pulsation of arteries. Heat and sweating, tremors and nervousness.Profuse salivation, excessive sweating. Pupils contracted.

BARYTA IODIDE
Enlarged, indurated glands. Tumours. Stunted growth.

CHROMIUM SULPHATE
Simple and exophthalmic goiters. Hypertrophy of glands. Tachycardia. Nerve tonic.

STROPHANTHUS
Exophthalmic goiters. Anaemia, palpitation, breathlessness. Heart’s action weak, irregular due to muscular debility. Tobacco heart.

DUBOISIA
Palliative in exophthalmic goiters. Trembling, numbness and weakness. Pupils dilated, dim vision.

THYMUS GLAND EXTRACT
High potencies efficient in exophthalmic goiters.

EPHEDRA
Exophthalmic goiters. Eyes feel pushed out with tumultuous action of heart.