enlargement

of
the thyroid
gland

Iodine deficiency
Goitrogen in the diet
Hashimotos thyroiditis
Subacute thyroiditis
Inadequate hormone synthesis
(dyshormonogenesis)
Tumors

EVALUATION
1.

Clinical criterion

2.

Functional criterion

3.

Etiopathogenic and geographic criteria

Physical examination

Observe the gland (the patient swallows); note

enlargement and nodularity, skin changes,
mobility
Palpate the gland anteriorly
Palpate the gland from behind the patient;
palpate the lymph nodes
Generalized enlargement is termed diffuse goiter;
Lumpy enlargement is termed nodular goiter

GOITER VOLUME (WHO, 1992)

0 degree: normal thyroid gland

1 st degree: palpable,but
not visible goiter

2 nd degree:
head in

visible goiter with the

normal position.

Patients with goiter

Clinical examination:
is imperfect
tends to be replaced by

Ultrasonographic
measurement:
V = AP x Tr x L x 0.52
Differentiates solid and cystic
masses

Thyroid ultrasound

Transversal

Soft

Firm:

cancer,
thyroiditis

Hard :

Cancer
Riedls fibrous thyroiditis

Position

normal

ectopic

Lingual goiter - acute respiratory

obstructive syndrome
Endothoracic goiter- often indistinct from
mediastinal tumors.

Increased acute/subacute
inflammations

spontaneously and
during palpation

Normofunctioning goiter

Hyperfunctioning goiter

Hypofunctioning goiter

an area is termed endemic (WHO) if

goiter is present in

10 % of general population
> 5 % of school population

mountain areas

occurs in

due to iodine deficiency

 coastal
familial
reactive
pregnancy,
puberty.

trace element,

indispensable for thyroid hormone

synthesis

Iodine content:
sea water- 50 micrograms/l
air- 0.5 micrograms/l
rain water,rivers-5 micrograms/l

Planetary ocean water

evaporation
clouds
rain

variable iodine scattering.

People consume iodine from:

drinking water
food (vegetable,meat)
air.

IODINE NECESSARY

infants (0-6 months)-

90 g /d

children (6 months-10 years)-

90-120 g /d

adolescents, adults-

150 g /d

pregnant womeng /d

175-200

CONSEQUENCES OF
IODINE DEFICIENCY

precocious abortion

increased mortinatality index

increased morbidity :
perinatal and
childhood

endemic cretinism

goiter

subclinical / overt hypothyroidism

goiter

endemic mental deficit

hypothyroidism

Neurological / psychiatric disorders

(myopathy,depression,deafness)

reducing fertility

The most affected regions of the

world are:
the Himalayas
the Andes
the Central Africa

In Europeiodine deficiency = maximal in:

Alps
Carpathians,
Balcanic Peninsula (especially)

Countries that efficiently control iodine

intake:

Sweden
Norway
Finland
Switzerland
Austria

Moderate to severe iodine deficiency:

Bulgaria
Greece
Germany
Turkey
Russia
Spain
Romania

Countries with normal areas

alternating with severe deficient
areas
Czech republic
Belgium
Denmark
Ireland
England
Portugal
Italy

According to WHO:
1.5 billion persons affected by
iodine deficiency
655 million persons present
goiter.

Endemic goiter=adaptive
pathology to iodine deficit

preferential synthesis of mono-iodotyrosine

preferential synthesis of T3 and reverse T3

inefficient negative feed-back

TSH increase

thyroid hyperplasia.

Other goitrogen factors

Inhibitors of iodine organification

(nitrates, chloride, fluorides, lithium
salts, goitrin; turnips, cabbage, soy
beam, )
Intoxication with methemoglobin
(excessive smoking - Tahiti)
Altered iodine absorbtion
(malabsorbtion syndrome, parasitosis,
calcium salts, iodophilic bacteria,
avitaminosis)

Goiter due to iodine

excess
1. Hokkaido goiter
- excessive laminaria ingestion
2. Changzou (China) goiter
- excessive amount of iodine in drinking
water.

hyperplasia of thyroid epithelium

hypothyroidism (iodine-induced
myxedema),
blockage in hormone synthesis by enzymatic
exhaustion and
blockage of iodine organification

functional stimulation (iodine-induced

Basedow)
intensification of thyroid autoimmunity.

genetic (individual inequality - iodine deficiency and

goitrogenous factors)
socio-economic
physiologic :
- pregnancy
- age
- sex
- weight
- muscular mass
hormonal :
- IGF-I
- nerve growth factor(NGF)
- epidermal growth factor(EGF)
- fybroblast growth factor(FGF)

Biochemical indicators
of goitrogenic process

serum:

thyroglobuline,
TSH,
T4,
T3

urinary iodine

(normal value 100-150 mcg/day)

Severity of endemic
dystrophy
1st degree:
urinary iodine 150100 mcg/day:
not affected

2nd degree:
urinary iodine 5025 mcg/day:
hypothyroidism (usually)

Iodine supplementation =obligatory.

3rd degree:
urinary iodine < 25 mcg/day:
cretinism (major risk) .

Lab consequences of
iodine deficit

increased RAIU (>50%)-iodine hunger

decreased PBI (protein-bound iodine)
urinary iodine <50 mcg/day
normal or decreased serum T4
elevated TSH and T3 (frequent rT3)
TRH stimulating test- high responsiveness
elevated serum thyroglobulin

CNS involvement = the embryo-fetal form of

endemy.
Goiter - present / not.
Clinical appearance - neurological manifestation
are severe :

lack of mental development

troubles of mielinisation process
epilepsy
dysartry
deafness,dumbness
conjunctive tissue dystrophy
myopathy,muscle atrophy
cretinism

the extreme form of endemy

long-existing endemic goiter outbreak

after 6-7 generations of goiter-bearers

iodine deficit in mothers diet

until the 75th -85th day of pregnancy,
irreversible cerebral lesions

3 forms of endemic cretinism

myxedematous
neurological
mixed

Goiter not
obligatory

impaired
development:
physical and
mental

hypothyroidism

The cretin may present:

encephalopathy (mental debility, disartria,
deafness, dumbness,
diskinesy, strabism,
imitative behavior)
displasias: hernias, congenital hip sprain
characteristic face: rigidity, indifference,
absence of mind.

!!! Endemic cretinism

vs.
Congenital myxedema

endemic cretin:
affected during intrauterine life.
substitutive therapy (thyroid hormones)- does
not improve I.Q..

congenital myxedema:
suffers after birth.
precocious hormonal replacement saves I.Q..

Iodization:

salt-20 mg KI/1 kg salt

oil ,
bread,
sugar
.

controlled diffusion of iodine in water (iodine is fixed on

silicon)

KI (potassium iodide) tb 1 mg:

children < 6 years -0.5 mg/wk

6-14 years of age- 1 mg/wk,

adults -1 mg/wk
pregnant women -2 mg/wk

iodine i.m.-100-150 mg, effective for 2 years

levo-thyroxine (L-T4):
100-150 mcg/day
increased doses at puberty, pregnancy,
menopause.

Surgery - indicated for

goiters that continue to grow despite L-T4 therapy
compressive goiters
substernal goiters

Endemic goiter
(diffuse / nodular)

Congenital myxedema
vs
Neurologic endemic cretinism

Endemic cretinism

Endemic cretinism

Endemic goiter in
Himalaya