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Referral and warning signs
When to refer
Refer to specialist (Endocrinologist/Surgeon) for: Suspicious nodule requiring FNA biopsy. Compressive symptoms (dyspnoea, dysphagia, hoarseness). Associated hyperthyroidism or hypothyroidism requiring management. Large goitre causing cosmetic concern. Consideration for surgery.
Red flags
- Rapidly enlarging goitre
- Hard, fixed nodule(s)
- Associated cervical lymphadenopathy
- Hoarseness
- Stridor or significant dyspnoea/dysphagia
- Symptoms/signs of malignancy
Signs and symptoms
- Visible or palpable swelling in the anterior neck.
- May be asymptomatic.
- Compressive symptoms (if large goitre): Dysphagia (difficulty swallowing), Dyspnoea (difficulty breathing, stridor - due to tracheal compression), Hoarseness (due to recurrent laryngeal nerve compression), Neck pressure sensation.
- Symptoms of associated thyroid dysfunction:
- - Hyperthyroidism: Weight loss, palpitations, heat intolerance, tremor, anxiety, sweating (see ENDO006).
- - Hypothyroidism: Weight gain, fatigue, cold intolerance, constipation, dry skin, depression (see ENDO007).
Risk factors
- Iodine deficiency (endemic goitre - common globally)
- Autoimmune thyroid disease (Hashimoto's thyroiditis - often hypothyroid; Graves' disease - hyperthyroid)
- Multinodular goitre (age-related changes)
- Thyroid nodules (benign adenomas, cysts)
- Thyroid cancer (less common)
- Thyroiditis (subacute, postpartum)
- Certain medications (e.g., Lithium, Amiodarone)
- Pregnancy, puberty (physiological goitre)
- Genetic factors
Diagnosis
Clinical assessment
Diagnosis based on physical examination confirming thyroid enlargement. Assess size, consistency (soft, firm, hard), symmetry, presence of nodules, tenderness, mobility with swallowing. Assess for compressive symptoms and signs of hyper-/hypothyroidism. Palpate cervical lymph nodes.
Investigations
- Thyroid Function Tests (TFTs): TSH (Thyroid Stimulating Hormone) is the best initial test. TSH low -> likely hyperthyroidism (check free T4/T3). TSH high -> likely hypothyroidism (check free T4). TSH normal -> euthyroid goitre.
- Thyroid Ultrasound: Assess thyroid size, structure (diffuse vs nodular), characterize nodules (size, solid/cystic, margins, calcifications, vascularity - assess risk of malignancy), guide fine needle aspiration.
- Fine Needle Aspiration (FNA) Biopsy: For suspicious or dominant thyroid nodules identified on ultrasound to rule out malignancy.
- Thyroid Autoantibodies (Anti-TPO, Anti-Tg, TRAb): If autoimmune thyroid disease (Hashimoto's, Graves') suspected.
- Radioactive Iodine Uptake (RAIU) Scan: Assess function of nodules (hot vs cold) if hyperthyroidism present (specialist).
Diagnostic criteria
Palpable or visible enlargement of the thyroid gland. Further characterization based on thyroid function tests and imaging.
Management
Non-pharmacological management
- Management depends on cause, size, symptoms, and thyroid function.
- Asymptomatic Euthyroid Goitre (Simple/Multinodular): Often observation with periodic monitoring (TSH, ultrasound).
- Iodine Supplementation: If due to iodine deficiency (e.g., iodized salt).
- Surgery (Thyroidectomy - partial or total): Indications include - Compressive symptoms, Suspicion/confirmation of malignancy, Cosmetic concerns, Thyrotoxicosis refractory to medical therapy.
Pharmacological treatment
- Treat associated thyroid dysfunction:
- - Hypothyroidism: Levothyroxine replacement (see ENDO007).
- - Hyperthyroidism: Antithyroid drugs (Carbimazole/Methimazole), Radioactive iodine, or Surgery (see ENDO006).
- Levothyroxine suppression therapy (to shrink goitre): Generally NOT recommended for euthyroid goitre due to limited efficacy and risks of subclinical hyperthyroidism.
Monitoring
Monitor thyroid size (palpation/ultrasound). Monitor TSH periodically (e.g., annually for euthyroid goitre). Monitor for development of compressive symptoms or thyroid dysfunction.
Complications
- Airway compression / Tracheal deviation
- Oesophageal compression / Dysphagia
- Recurrent laryngeal nerve palsy / Hoarseness
- Development of hyperthyroidism (toxic multinodular goitre)
- Thyroid malignancy (in a nodule)
- Cosmetic concerns
Prevention
- Adequate iodine intake (iodized salt programs) - prevents endemic goitre.
Patient education
- Explain goitre and likely cause.
- Reassurance if simple euthyroid goitre.
- Need for monitoring (TSH, ultrasound).
- Symptoms of compression or thyroid dysfunction to report.
- Treatment options if needed (medication for dysfunction, surgery).
Uganda-specific notes
Iodine deficiency endemic goitre was historically common, reduced by salt iodization but may still occur. Evaluation capacity (TFTs, Ultrasound, FNA) limited outside main centers. Need to consider TB thyroiditis.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 8, Section 8.1.5