Simple goitre is an enlargement of the thyroid with no cancer or inflammation and normal thyroid function. The thyroid enlarges as shown in the diagram.
As the goitre gets bigger it may cause the following complications
· Difficulty in swallowing· Change in voice· Breathlessness· Facial congestion
Many patients leave their unsightly goitres for years. It is strongly recommended that such patients be reviewed regularly. It is particularly important if any of the above complications occur that they seek urgent medical advice. In addition simple goitres may become overactive or underactive. The signs to look out for are:
Puffy face constipation
Loss of libido
Thyroxine treatment has been used for years in the hope that it would stop simple goitres from growing. The principle of this treatment is to give thyroxine in order to decrease the TSH by negative feedback. The results of studies have been equivocal. Small goitres are more responsive to thyroxine therapy than large ones but once the treatment is stopped the goitre returns to its pre-treatment size. There is no evidence that thyroxine treatment changes the progression of a simple goitre.
Thyroxine treatment is not without its problems. Small cancers can shrink initially on thyroxine treatment only to enlarge later. Thyroxine may produce subclinical hyperthyroidism with the risk of accelerated osteoporosis in postmenopausal women. Finally simple goitres may spontaneously become overactive, emphasising the need to check the T3, T4 and TSH in patients on thyroxine therapy.
Which type of operation should be performed?
Removing the nodules alone is usually unacceptable because this has a very high recurrence rate. The ideal operation is the removal of all the thyroid tissue (total thyroidectomy). This approach has the disadvantage of life long thyroxine medication and the parathyroid glands may be damaged either temporarily or permanently (25% and 2-5% respectively). Damage to the parathyroids necessitates long-term calcium and vitamin D replacement. Because this complication may occur at higher rates in non-specialist hands many centres do a less radical procedure leaving a considerable amount of thyroid tissue behind hoping to reduce the occurrence of parathyroid damage (subtotal thyroidectomy). Such an approach has a 15% risk of recurrence of the goitre. It must be remembered that first time surgery has a very small risk of permanent voice change (1%) but in any subsequent surgery voice change is more common (up to 30%).