Thyroid swellings and enlargement
What is the thyroid?
The thyroid is a butterfly shaped gland located at the base of the throat where the joining of the collarbones dip, just below the Adam’s apple. The thyroid secretes various hormones, the main one being thyroxine. Thyroid hormones influence many of your body’s operations, from metabolism to growth and development to body temperature. It is also important for brain development during infancy and childhood.
The thyroid has two lobes. Some conditions may cause the thyroid to swell, enlarge or develop growths. The entire gland may be enlarged or a growth could be protruding to the outside. Enlargement is common in 20% of people.
Most of the time they are harmless and benign. But if you do feel or see a swelling, you should visit a surgeon, preferably one specialized or experienced in thyroid surgery.
Reasons for enlargement
- Iodine deficiency: If you have iodine deficiency, your thyroid could grow to become very large. Iodine deficiency is normally noticed in mountainous or land-locked areas where there is no seafood. Many of these inhabitants have enlarged thyroid. This enlargement is benign.Because of physiological changes the thyroid adapts to its new enlarged state so that it can continue to distribute the hormone thyroxin. Usually, when the thyroid enlarges because of iodine deficiency it does not revert to its original smaller size. This enlargement is permanent. It could be controlled with iodine, though not always. If the enlarged thyroid is big and bothersome for you, your doctor can remove it through surgery.Diffuse enlargement is the term given to enlarged thyroid where there are no growths.
- Inflammation: A weakened immunity of the thyroid is the main reason for an infection. Cells start attacking the thyroid gland and the gland enlarges. It is not a bacterial infection and it might only give you a little pain. It may also impact the secretion of the gland in a way that would lead it to increase (hyperactive) or decrease (hypoactive) its secretions. This does not usually require treatment. Your doctor will need to monitor the changes in the secretion of the gland and then decide if treatment is required.Other types of infections are bacterial, but they are not common.
- Growths, nodules and sacs: Your thyroid gland may enlarge if you have one growth, which could appear as a small lump or many lumps. This is a common condition known as goiter, which is a general term for thyroid enlargement. In some cases there are nodules or sacs. Nodules are also common and are related to secretions that are collected in a particular place like a sac, or part of the gland becomes hyperactive and it develops into a nodule. Most of these are benign.
Less common are some nodules that are malignant. They occur in less than 10% of cases in Jordan where only one nodule is seen. Malignant multi-nodule cases are even less frequent. It is not easy to differentiate a benign from a malignant nodule with an initial examination or simply by looking at it. Doctors can discover its nature by doing an ultrasound.In approximately 90% of the cases these are benign and no intervention is necessary. In this case, the nodule will remain as is for the rest of your life. Many patients question why these nodules are not removed and whether they could in the future turn into a malignant nodule. You do not need to worry. The benign nodule will not ever become malignant.
Symptoms of enlarged thyroid
- You may feel a lump.
- You may experience difficulty swallowing.
- You may experience difficulty breathing.
- You may have pain before it enlarges which indicates the onset of infection and then the gland could start to enlarge.
As long as there are no infections while there are growths, the thyroid function remains intact. Some doctors prescribe hormones but these are completely useless and there are other side effects of hormones as well.
Your doctor must differentiate between an enlargement of the thyroid and a lump and whether it is benign or malignant. Your doctor will first perform an ultrasound and if results are inconclusive your doctor will request a biopsy. If this is also uncertain, surgery is the third and last option. The whole process is like an algorithm: well-defined procedures for every step so your doctor can accurately diagnose the enlargement or lump.
An ultrasound is the most important means of investigating a malignancy as it determines all the features. Your doctor can see, for example, whether a nodule is a simple sac filled with secretions from the gland itself, which does not cause any alarm and does not warrant further investigation.
Sometimes, the radiologist reports a nodule that looks suspicious and the report is inconclusive. In this case, your doctor will request a biopsy.
A biopsy is a simple 5-minute test undertaken by inserting a small needle into the gland under ultrasound guidance at a hospital or clinic, which will tell your doctor if the growth is malignant or benign. In some cases, the results are inconclusive. If this is so, surgery is the next step.
Surgery is performed as a very last resort only and in cases where there is a proven malignancy.
A small, aesthetic incision is made from the lower throat. Surgery lasts between 1-1.5 hours if the lump is on one side of the gland and slightly longer if it is on both sides.
The operation is not painful and your recovery is quick. You can resume normal life within a few days.
Your doctor may ask you to stay in hospital overnight or leave on the same day if the surgery was simple and on one side.
The surgery in itself is not difficult, but rather it is delicate because there are anatomic structures close to the gland, which must not be damaged, as this may affect your vocal chords. The complications are uncommon with experienced surgeons who perform at least 10-20 similar operations each year. Training is the most vital aspect because top-notch training will teach doctors technical skills on how to do it the right way. Surgical experience with no training can lead to adverse results.
The thyroid is full of blood vessels and nerves that lead to the vocal chords. During surgery they may get cut or sustain slight damage with inexperienced surgeons. As a result, your voice may become hoarse for a few weeks or months and improve with time, or your voice could be permanently changed. This is an important issue for teachers or other professionals who use their voice.
Your breathing may also be affected after surgery.
When should surgery be an option?
- When you have inconclusive biopsy results.
- When you have difficulty breathing: In some patients, glands can become over enlarged and cause breathing difficulties. When the lower glands enlarge, they could put pressure on the windpipe (trachea), especially while sleeping. In this case, removal of the affected part of the gland becomes a necessary option.
- When you have aesthetic reasons: Some patients do not like the look of their enlarged thyroid.
Parathyroid glands are our tiny endocrine glands located behind the thyroid gland. These do not show clearly on ultrasound and might be removed with the gland during surgery.
Parathyroid glands control the amount of calcium in the bloodstream. If your surgeon accidentally removes 3 or 4 of these glands or causes any damage, the level of calcium in the blood will be reduced, which causes complications especially to the nerves and heart. In that case you will have to take calcium supplements or injections for a while, or for life.
Patients outside of Jordan
If you are outside Jordan and would like to consult with your doctor at Al-Khalidi Hospital and Medical Center, please visit our website (www.khmc.jo) for more information and to make arrangements with your doctor.
Three main points to remember:
- Surgery should be a last resort and only for the necessary cases.
- Most nodules do not require surgical intervention because they are for the most part benign and will not turn into malignancies.
- If there is a need for an operation, a specialized experienced surgeon must perform it.
This information was provided by Consultant General Surgery & Surgical Oncologist, Al-Khalidi Hospital and Medical Center, Dr Basem Morcos.