*5.1.1 History and examination*

Extensive history should be taken in all patients with goiter (**Table 2**).

Following points should be highlighted while taking history like place of residence (patients from high altitude areas iodine deficient), dietary iodine intake, family history of thyroid disorders, radiation exposure and any history of goitrogenic drugs intake.


#### **Table 2.**

*Differential diagnosis of swelling in anterior aspect of neck.*

Major concern of nodular thyroid disorder is development of malignancy. Hence history regarding risk factors for malignancy like age (<20 and >60 years), male sex, previous radiation exposure, family history of thyroid malignancy, MEN 2A syndrome should be obtained.

#### **5.2 Clinical evaluation**

#### *5.2.1 Physical examination*

The thyroid examination is done with patient in sitting or standing position. Goiter is classified according to World Health Organization (WHO) classification [11] (**Table 3**).

Thyroid gland is palpated from behind the patient with neck relaxed and looked for size, consistency, nodules, and tenderness and lymphadenopathy.

Consistency of the enlarged gland helps in making diagnosis. Lesions which are hard for palpation suggest malignancy but rarely Reidel's thyroiditis may present like this. The gland feels rubbery in Hashimoto's thyroiditis. Diffuse tenderness can be elicited in sub-acute Thyroiditis.

Palpable thrill and hearing of bruit during auscultation over the gland suggest hypervacularity, it is seen in condition like Graves' disease.

During local examination one should look for lymphadenopathy and following group of lymph nodes should be examined (1) supraclavicular nodes, (2) anterior cervical chain lymph nodes, (3) posterior cervical chain lymph nodes, and (4) submental lymph nodes.

#### *5.2.1.1 Pemberton's maneuver*

The patient is advised to rise both the arm till they touch the face on respective sides. The test is considered positive if patient develops facial plethora. Thyroid gland obstructing thoracic inlet which lead to venous obstruction is considered to be the underlying mechanism.


**Table 3.** *WHO classification of goiter.*


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*Goiter: Overview of Aetiopathogenesis and Therapy DOI: http://dx.doi.org/10.5772/intechopen.90028*

General • Lethargy • Somnolence • Weight gain • Cold Intolerance Cardiovascular • Bradycardia • Angina

**Table 5.**

**Tables 4** and **5** respectively.

*Signs and symptoms of hypothyroidism.*

• Congestive heart failure • Pericardial Effusion Hematological • Anemia

*5.2.2 Investigation*

*5.2.2.1 Thyroid function test*

*5.2.2.2 Thyroid peroxidase antibodies*

*5.2.2.3 Thyroid ultrasound*

General examination includes looking signs of hyperthyroidism, hypothyroidism

Symptoms of thyroid malignancy: Most commonly manifest as solitary nodule which are usually painless in nature. Malignant conversion of thyroid nodules is more common among males than females. Hoarseness of voice and dysphagia sug-

Malignant nodules on palpation range from soft to hard consistency. Regional

Thyroid function test is evaluated starting with measurement of measurement of serum TSH level. If TSH level are less than normal values then next step is to measure T3 and. Normal T3 and T4 level (total T4: 4.5–12.5 μg/dL, free T4: 0.8–1.7 ng/dL, total T3:0.8–2.0 ng/ml, free T3: 2.3–4.2 pg./mL) suggest subclinical hyperthyroidism whereas elevated T3 and T4 level suggest overt hyperthyroidism. Both overt and subclinical hyperthyroidism suggest Graves' disease or toxic MNG. If TSH levels are less than normal value then next step is to measure T4 level. Subclinical hypothyroidism is considered when value of TSH levels between 5 and 10 *μ*U/ml with normal T4 level. Iodine deficiency and Hashimoto's thyroiditis are

Presence of the antibody in serum suggest autoimmune thyroid disorder

Even though all patients with enlarged thyroid gland requires sonographic assessment to rule out malignancy, risk decreases in patients having TSH below normal or in low normal range. There are certain indications which make ultrasound assessment

and metastatic involvement of different organs in suspected thyroid malignancy. Signs and symptoms of hyperthyroidism and hypothyroidism are enlisted in

Reproductive system

• Infertility • Menorrhagia

Dermatological • Dry flaky skin and hair

Neuromuscular • Aches and pains • Muscle stiffness • Carpel tunnel syndrome

• Hoarseness • Cerebellar ataxia

• Myotonia • Depression • Psychosis

• Delayed deep tendon reflex

• Myxedema • Malar flushes • Vitiligo • Carotenemia Gastro-intestinal • Constipation • Ileus • Ascites

gest local involvement of recurrent laryngeal nerve and digestive tract.

the most common cause of subclinical or overt hypothyroidism.

lymphadenopathy suggests lymph node metastasis.

#### **Table 4.**

*Symptoms and signs of hyperthyroidism.*

*Goiter: Overview of Aetiopathogenesis and Therapy DOI: http://dx.doi.org/10.5772/intechopen.90028*


#### **Table 5.**

*Goiter - Causes and Treatment*

syndrome should be obtained.

be elicited in sub-acute Thyroiditis.

**5.2 Clinical evaluation**

*5.2.1 Physical examination*

[11] (**Table 3**).

mental lymph nodes.

palpation

*WHO classification of goiter.*

**Table 3.**

*5.2.1.1 Pemberton's maneuver*

be the underlying mechanism.

Grade 0: No goiter is palpable or visible.

Major concern of nodular thyroid disorder is development of malignancy. Hence history regarding risk factors for malignancy like age (<20 and >60 years), male sex, previous radiation exposure, family history of thyroid malignancy, MEN 2A

The thyroid examination is done with patient in sitting or standing position. Goiter is classified according to World Health Organization (WHO) classification

for size, consistency, nodules, and tenderness and lymphadenopathy.

hypervacularity, it is seen in condition like Graves' disease.

Grade 1: Palpable goiter, not visible when neck is held in normal position

**Increased sweating Onycholysis** Hyperpigmentation Thinning of the hair Systolic hypertension Increase appetite Weight loss Palpitation Heat intolerance Insomnia

Eye: lid retraction, lid lag, exophthalmos, ophthalmoplegia

*Symptoms and signs of hyperthyroidism.*

Thyroid gland is palpated from behind the patient with neck relaxed and looked

Consistency of the enlarged gland helps in making diagnosis. Lesions which are hard for palpation suggest malignancy but rarely Reidel's thyroiditis may present like this. The gland feels rubbery in Hashimoto's thyroiditis. Diffuse tenderness can

Palpable thrill and hearing of bruit during auscultation over the gland suggest

During local examination one should look for lymphadenopathy and following group of lymph nodes should be examined (1) supraclavicular nodes, (2) anterior cervical chain lymph nodes, (3) posterior cervical chain lymph nodes, and (4) sub-

The patient is advised to rise both the arm till they touch the face on respective sides. The test is considered positive if patient develops facial plethora. Thyroid gland obstructing thoracic inlet which lead to venous obstruction is considered to

Grade 2: A clearly swollen neck (also visible in normal position of the neck) that is consistent with a goiter on

Hyper defecation Menstrual irregularity oligo-/hypomenorrhea

**8**

**Table 4.**

*Signs and symptoms of hypothyroidism.*

General examination includes looking signs of hyperthyroidism, hypothyroidism and metastatic involvement of different organs in suspected thyroid malignancy.

Signs and symptoms of hyperthyroidism and hypothyroidism are enlisted in **Tables 4** and **5** respectively.

Symptoms of thyroid malignancy: Most commonly manifest as solitary nodule which are usually painless in nature. Malignant conversion of thyroid nodules is more common among males than females. Hoarseness of voice and dysphagia suggest local involvement of recurrent laryngeal nerve and digestive tract.

Malignant nodules on palpation range from soft to hard consistency. Regional lymphadenopathy suggests lymph node metastasis.

#### *5.2.2 Investigation*

#### *5.2.2.1 Thyroid function test*

Thyroid function test is evaluated starting with measurement of measurement of serum TSH level. If TSH level are less than normal values then next step is to measure T3 and. Normal T3 and T4 level (total T4: 4.5–12.5 μg/dL, free T4: 0.8–1.7 ng/dL, total T3:0.8–2.0 ng/ml, free T3: 2.3–4.2 pg./mL) suggest subclinical hyperthyroidism whereas elevated T3 and T4 level suggest overt hyperthyroidism. Both overt and subclinical hyperthyroidism suggest Graves' disease or toxic MNG.

If TSH levels are less than normal value then next step is to measure T4 level. Subclinical hypothyroidism is considered when value of TSH levels between 5 and 10 *μ*U/ml with normal T4 level. Iodine deficiency and Hashimoto's thyroiditis are the most common cause of subclinical or overt hypothyroidism.

#### *5.2.2.2 Thyroid peroxidase antibodies*

Presence of the antibody in serum suggest autoimmune thyroid disorder

#### *5.2.2.3 Thyroid ultrasound*

Even though all patients with enlarged thyroid gland requires sonographic assessment to rule out malignancy, risk decreases in patients having TSH below normal or in low normal range. There are certain indications which make ultrasound assessment mandatory like palpable solitary nodule, palpable multinodular goiter, and suspicion of nodule in patient with difficult neck palpation, rapid growth of a goiter, thyroid asymmetry, firm consistency, tenderness, normal TSH and negative TPO antibodies.

### *5.2.2.4 Fine-needle aspiration cytology*

Indications for FNAC include rapid growth of the swelling which suggest malignant transformation, signs of inflammation (abscess formation) and nodules with indeterminate or suspicious features (ultrasound proven).

### *5.2.2.5 Computed tomography of neck*

Computed tomography of neck not usually advised is required rarely to assess the extension of large cervical goiters and sub sternal goiters.
