Goiter
Goiter of the thyroid is the medical designation for an enlargement of the thyroid tissue. The term generally refers to glandular swelling, regardless of the visible shape, fine tissue structure or functional position of the thyroid gland, which can be normal ( euthyroidism ), increased ( hyperthyroidism ) or decreased ( hypothyroidism ). A goiter as the palpable, visible and measurable enlargement of the thyroid gland in the throat is also called goiter (outdated: satiety throat ).
Goiter is the most common disease of the hormonal glands (an endocrinopathy ) worldwide . The most common cause of goiter is an iodine deficiency . In addition to drug therapy with iodine or thyroid hormones, treatment options include thyroid surgery and radioiodine therapy .
The term "goiter", which also describes a bulging of the esophagus in birds , is derived from the Indo-European greup . "Greup" means "to curve" and refers to the neck veins that are curved on a goiter. The term "struma" ( struma , engorgement ' ; plurality Strumae or eingedeutscht Strumen ) was 1718 by Lorenz Heistermann and later by Albrecht von Haller introduced in the medical literature.
Classification
| Classification according to ICD-10 | |
|---|---|
| E01 | iodine deficiency related thyroid diseases and related conditions |
| E01.0 | iodine deficiency-related diffuse goiter (endemic) |
| E01.1 | multi-nodular goiter caused by iodine deficiency (endemic) |
| E01.2 | iodine deficiency-related goiter (endemic), unspecified |
| E04 | other non-toxic goiter |
| E04.0 | nontoxic diffuse goiter |
| E04.1 | non-toxic solitary thyroid nodule |
| E04.2 | nontoxic multinodular goiter |
| E05 | Hyperthyroidism (thyrotoxicosis) |
| E05.0 | Hyperthyroidism with diffuse goiter - Graves' disease |
| E05.1 | Hyperthyroidism with toxic solitary thyroid nodule |
| E05.2 | Hyperthyroidism with toxic multinodular goiter |
| ICD-10 online (WHO version 2019) | |
According to its expression ( morphologically ), a diffuse goiter (evenly enlarged) is distinguished from a nodular goiter (already present). The uninodular goiter has a single nodule , the multinodular goiter several.
Depending on the position, the eutopic goiter (normal anatomical position) is differentiated from the dystopic goiter (goiter in the chest ( retrosternal ), behind the trachea or under the tongue).
According to its function (functional), a distinction is made between euthyroid goiter (normal metabolic values ) from hypothyroid goiter (if underactive ) and hyperthyroid goiter or toxic goiter (if overactive ).
According to their occurrence ( epidemiological ): If more than 10% of the population is affected within an area, one speaks of an endemic goiter , otherwise of a sporadic goiter .
After their dignity is between the goiter maligna containing a malignant tumor, which is generally is a thyroid carcinoma is, and the bland goiter distinguished, it is in a non-inflammatory, benign thyroid enlargement at normal (euthyroid) metabolism. A goiter that recurs after therapy is called recurrent goiter .
The World Health Organization (WHO) differentiates the following goiter grades according to size, each of which is cited with minimal differences:
| Classifications of the degrees of goiter | |||
| according to Hotze and Schumm-Dräger | according to AWMF guidelines | ||
| Grade 0a | No goiter | Stage 0 | No goiter |
| Grade 0b | Palpable but invisible goiter | Stage 1a | Palpatory but invisible enlargement |
| Grade I. | Palpable goiter, just visible when the head is bent back | Stage 1b | Visible enlargement at maximum neck reclination |
| Grade II | Visible goiter | Stage 2 | Thyroid visible with normal head position |
| Grade III | Large visible goiter | Stage 3 | Heavily enlarged thyroid |
The classification of a patient in this grade depends on the one hand on subjective factors of the examiner, on the other hand on the nutritional status of the patient and the development of the neck muscles. It can therefore only be used as an orientation description of the finding, not to give the exact size of the thyroid gland.
causes
The most common cause of goiter worldwide is a diet-related, so-called alimentary, iodine deficiency at around 90 percent .
Other, less common etiological factors must be distinguished from this. These include thyroid autonomy , autoimmune diseases of the thyroid gland (which Autoimmunthyreopathien Graves' disease and Hashimoto's thyroiditis ), certain craw causing so-called goitrogenic, medications (eg lithium and anti-thyroid drugs ) and other goitrogenic substances (for example, thiocyanate and nitrate ), inflammation of the thyroid tissue ( thyroiditis ), Cysts in the thyroid gland and benign and malignant tumors of the thyroid gland, with malignant changes in the thyroid gland in particular thyroid cancer and, more rarely, metastases of malignant tumors from other tissues and organs of the body into the thyroid gland.
Other rare causes of a goiter are benign tumors of the pituitary gland (pituitary) , a molar pregnancy , a acromegaly , thyroid hormone synthesis, a peripheral thyroid hormone resistance , a sarcoidosis , an amyloidosis , parasites and more. The smoking of tobacco and a lack of selenium are also discussed as causes of a goiter.
frequency
Around one billion people worldwide live in iodine-deficient areas. Around 200 million people suffer from goiter due to iodine deficiency. Because goiter used to be so common in these iodine deficiency areas, it is also known as endemic goiter . Around 20 million people who live in areas with pronounced iodine deficiency suffer from the consequences of prenatal or early childhood iodine deficiency.
In Germany, more than 30 percent of adults have an enlarged thyroid or thyroid nodules. With reference to the Papillon study, Hotze (2003) comes to the conclusion that earlier assumptions about a north-south divide in frequency within Germany and a significant difference in frequency between men and women have not been confirmed.
In Switzerland , the prevalence of iodine deficiency goiter has fallen significantly, since table salt has been enriched with iodine since 1919 due to the iodine-poor soils.
Development of iodine deficiency goiter
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The ideas about the pathogenesis of goiter have changed in the last few decades. Until the mid-1980s, it was assumed that iodine deficiency leads to a slight hypothyroidism and that subsequently the pituitary gland ( pituitary ) production of the hormone TSH increased thyroid growth to stimulate the uptake of iodine and thyroid hormone production. Experimental work on cultivated thyroid cells has shown, however, that an increased TSH level only leads to the proliferation of thyroid cells (thyrocytes) if there is also an iodine deficiency within the cells.
Today, the following mechanisms can be considered to be certain: Thyroid tissue poor in iodine releases certain growth factors (the IGF , the EGF , the TNF-α and the FGF ), which act on the releasing cells themselves and their neighboring tissue ( autocrine and paracrine secretion). These factors lead to a cell proliferation ( hyperplasia ) of the thyroid follicles, as well as to the proliferation of certain connective tissue cells ( fibroblasts ) and the injection of blood vessels. Thyrocytes , on the other hand, that are sufficiently supplied with iodine produce the growth-inhibiting factors TGF-b and iodine- lactones . The TSH also promotes the growth of the individual thyrocytes ( hypertrophy ), but changes the effect of the individual growth factors in different directions.
These processes are initially not pathological, but serve the normal ( physiological ) adaptation of the thyroid gland to phases of relative iodine deficiency. With years of iodine deficiency there are additional degenerative changes in the thyroid gland, in the course of which nodular changes occur, as well as the formation of autonomous areas that have decoupled from the control loop between the pituitary and thyroid glands. So you no longer react to attempts to control the TSH .
Complaint picture
The clinical picture of a goiter patient depends primarily on the size of the thyroid gland and the metabolic status.
A slight enlargement of the thyroid usually does not cause any local complaints. With the increasing size of the thyroid gland, however, more and more patients complain of a feeling of pressure, tightness or lumpiness, abnormal sensations when wearing tight collars, difficulty swallowing, shortness of breath during exercise, shortness of breath depending on the position of the head and a tendency to bronchitis . A third-degree goiter can mechanically displace neighboring structures ( trachea , throat vessels, esophagus ) and lead to corresponding symptoms , such as pronounced swallowing difficulties or shortness of breath (possibly even at rest) and stridor .
If a metabolic thyroid autonomy has developed, the patients often complain of symptoms in the sense of hyperthyroidism (see there). There is a risk of developing a thyrotoxic crisis, particularly after excessive iodine administration in the form of contrast media containing iodine or amiodarone .
Investigations
Main article: Examination of the thyroid gland
In addition to palpation of the neck, ultrasound is primarily used as a diagnostic method to detect a goiter. The extent of the thyroid gland can be measured in the three spatial axes and the volume can be calculated from this ( ellipsoid ). Newer ultrasound devices also provide direct 3D volumetry of the thyroid. The thyroid gland has a normal volume of up to 18 ml in women and up to 25 ml in men.
For further clarification, the thyroid hormones T3 and T4 , thyrotropin (TSH) and possibly autoantibodies ( TRAK , TPO-AK ) are determined in the laboratory . For nodes which follow thyroid scintigraphy with 99m Tc and suspected carcinoma of the thyroid , where appropriate, a cytopathological examination after fine needle biopsy . An iodine deficiency can be detected by measuring the iodine excretion in the urine or, more simply, by an increased absorption of the tracer in the scintigram .
The X-ray target image of the trachea and esophagus (possibly with contrast agent ) have largely been replaced by the ultrasound examination. If the goiter grows into the chest, computed tomography (CT) or magnetic resonance imaging (MRI) is occasionally necessary, in the case of a dystopic thyroid gland (deviating position) a scintigram with 123 I is rarely necessary .
If an operation is planned, you will also see an ear, nose and throat doctor in order to rule out existing disorders of vocal cord mobility or recurrent palsy (paralysis of the vocal cord nerves, recurrent nerve ).
treatment
The following forms of therapy are available for the treatment ( therapy ) of goiter: drug therapy, surgery and radioiodine therapy .
Medical therapy
According to the ideas about the pathogenesis (see development of iodine-deficient goiter), the drug treatment of goiter consisted until well into the second half of the 20th century in the administration of thyroid hormones in a dosage that, via the thyroid control circuit, led to a lowering of the TSH value below the Normal range led (TSH suppression). With this, however, one accepts the negative consequences of latent hyperthyroidism for the patient , in particular the increased likelihood of certain cardiac arrhythmias ( atrial fibrillation ) and the loss of bone mass ( osteoporosis ) occurring .
In the Struma diffusa and the nodular goiter without relevant autonomy and without carcinoma suspicion standard therapy today consists of the administration of iodide or combination products of iodide and L - thyroxine , because both substances synergistically acting on hypertrophy and hyperplasia of the thyroid gland. TSH suppressive therapy and monotherapy of goiter diffusa with L- thyroxine are considered obsolete, as this leads to further iodine depletion within the thyroid gland and renewed thyroid growth as soon as the medication is stopped. The aim of drug therapy is to prevent the formation of new nodes, to prevent any further growth of any existing nodes and to shrink the non-nodular tissue. The same treatment is used to prevent ( prophylaxis ) a relapse of goiter after goiter resection and in the case of latent or overt hypothyroidism after surgery or radioiodine therapy .
The daily dose of iodide is usually 100 to 200 µg. The amount of L- thyroxine administered is based on the TSH value, which should be in the lower normal range, but should not be suppressed. The duration of treatment is usually 12 to 18 months, then you can often switch to therapy with iodide alone. In the case of hypothyroidism, therapy is generally lifelong, after thyroid surgery usually also for life.
Absolute contraindications to drug therapy are pre-existing latent or overt hyperthyroidism due to the risk of a thyrotoxic crisis and the suspicion of thyroid cancer. Relative contraindications are an existing autonomy with a normal metabolic situation ( euthyroidism ) or the development of latent hyperthyroidism during therapy. In the presence of autoimmune thyroiditis , L- thyroxine is used alone . Hyperthyroidism with too high a dose of L- thyroxine and new or worsening acne are described as side effects .
Operative therapy
The operation of the thyroid gland is absolutely indicated if there is a specific suspicion of thyroid carcinoma as well as if there is mechanical impairment of neighboring structures (narrowing of the trachea over 50%, tracheomalacia , narrowing or displacement of the esophagus , upper congestion ). A relative indication exists in the case of a growth tendency of the thyroid gland in spite of drug therapy, cold nodules without a specific malignancy suspected and in the case of dystopic thyroid tissue and for cosmetic reasons.
Thyroid surgery is usually done as:
- Goiter resection (partial removal of the thyroid gland) in all benign ( benign ) nodular goiter
- Thyroidectomy (complete removal of all visible parts of the thyroid gland) in the case of a previously known or intraoperatively confirmed malignant tumor ( malignancy )
- Hemithyroidectomy (complete removal of all visible parts of a thyroid lobe ) for unilateral (multiple or solitary) thyroid nodules with a healthy opposite side
Rare but typical complications of all thyroid operations are damage to the vocal cord nerve ( recurrent palsy ) and postoperative underactive parathyroid glands ( hypoparathyroidism ). The risk of these complications is higher in the case of a second procedure and surgery on malignant thyroid tumors. By using special devices for intraoperative visualization of the recurrent laryngeal nerve ( neuromonitoring ), the frequency of vocal cord nerve paralysis can be significantly reduced in all thyroid operations and, in the hands of the experienced surgeon, is less than 1%. Postoperative bleeding, damage to the superior laryngeal nerve and wound infections after thyroid surgery are very rare .
The various thyroid operations do not eliminate the cause of the goiter formation, but on the contrary, by reducing the body's own ability to provide thyroid hormones, intensify the growth stimuli on the residual thyroid tissue. Therefore, as a prevention ( prophylaxis ) of renewed thyroid growth and renewed nodule formation after the operation, a mostly lifelong combination treatment with iodide and L- thyroxine is required (see drug therapy ).
Radioiodine therapy
Main article: Radioiodine therapy
Radioiodine therapy is an effective method of reducing the size of the thyroid gland and eliminating autonomous areas, as well as treating Graves' disease . It is also used in the treatment of goiter maligna after previous surgery. It plays a subordinate role in the treatment of benign goiter with normal function ( bland goiter ), but is used when an operation is undesirable or not possible.
prevention
For general prevention ( prophylaxis ) of thyroid enlargement, table salt and increasingly other foods and certain types of feed for various farm animals are enriched with iodine in numerous countries . As a result, the iodine supply of the population in the affected countries has improved significantly and the frequency of goiter has decreased significantly, especially in children and adolescents.
An accumulation of autoimmune diseases of the thyroid due to the increased iodine supply is discussed. For example, after taking more than 500 µg iodine per day for a year, there is an increased amount of thyroid autoantibodies in the blood, but hypothyroidism is not accumulated . The Federal Institute for Risk Assessment (BfR) “sees no increased risk for the exacerbation of thyroid diseases or even for the triggering of secondary diseases through the current practice of using iodized salt in the household, in communal catering and in particular in the production of baked goods and Meat products. This also applies to the consumption of iodized animal foods such as milk, cheese, eggs or meat as a result of the iodination of feed. "
An indication for an additional administration of iodide (in tablet form) is given to people in whose families goiter has already occurred at an earlier point in time (positive family history ), during pregnancy and breastfeeding as well as after completion of drug therapy. For infants and children up to 10 years of age, 100 µg / day is recommended, for children over 10 years and adults 150 to 250 µg / day.
Medical history
The oldest evidence of goiter is over 4000 years old and can be found in China, India and Egypt. In Central Europe it was known early on that there were regional differences in frequency. Vitruvius described the occurrence of goiters among the inhabitants of the Alps and the Sabine mountains as early as 16 AD . He suspected the cause was in the water.
The Chinese Sun Si Miao carried out goiter therapies with herbs from animal thyroid glands as early as the 7th century AD. According to the sources, these should have led to a reduction in the goiter.
In the 16th century Paracelsus also wrote about goiter and was one of the first doctors to see a connection with the clinical picture of cretinism.
The Scottish philosopher David Hume described his impressions from Styria in 1748 with shock : “As appealing as the country is in its roughness, so wild, disfigured and monstrous are the inhabitants in their appearance. Very many of them have ugly swollen necks. Cretins and the deaf and dumb frolic in every village. The general sight of the people is the most shocking I've ever seen. "
In 1791, Pierre-Joseph Desault was probably the first doctor to perform the surgical removal of an enlarged thyroid lobe. The first systematic studies on the regional distribution of goiter were carried out in the Kingdom of Sardinia in 1845. Goiter formations can be found not only in the Alpine countries, but also in Northern Europe.
Jean-Francois Coindet (1774–1834) carried out first attempts at therapy with the iodine, discovered shortly before, in Switzerland in 1820 , after he had proposed to Jean-Baptiste Dumas in 1818 the chemical examination of charred sponges for iodine content and this iodine tincture and potassium iodide as medicinal products found a beneficial effect on goiter. From 1850 iodine was tried in France for prophylaxis (prevention). Due to a dose that was far too high, however, there were sometimes fatal courses of therapy. In the 1850s, Louis Pasteur thought goiter was an infectious disease . Moritz Schiff carried out experiments with thyroid extracts from sheep in 1880. In 1901 Philipp Schech treated goiter patients with "thyrojodine", thyroid substances from mutton or pork.
In Switzerland, Otto Bayard introduced the correctly dosed iodized salt in 1918 in Mattertal and Hans Eggenberger in 1922 in the canton of Appenzell Ausserrhoden . Corresponding iodized salt was also introduced in the USA in 1924, in Austria in 1963 and in the Federal Republic of Germany in 1976, whereby in the Federal Republic of Germany this was provided with the warning "Only to be used if a doctor diagnosed iodine deficiency" until 1981. From 1983, table salt was iodized across the board in the GDR . Transitional regulations for the new federal states applied until 1991.
Cultural aspects
In earlier times it was thought that the cause of a goiter was caused by anger and the associated holding of breath. Different idioms result from this idea . Emptying your goiter means speaking your mind, releasing all anger. Something is superfluous like a goiter indicates that something is a hindrance. The oldest currently known, documented evidence of this expression comes from the Social Democratic Library, Volume 3, from 1890: “Such a bourgeois, for human society, for the state as superfluous as a goiter , as harmful as an eating cancer, reigns in this state ... "
As a piece of jewelry, the choker is part of the Bavarian and Austrian costume . The goiter band is said to have its origin in the Salzburg region . The iodine deficiency there has led to an increase in the size of the thyroid gland for centuries. At least since the 19th century, women have worn goiter bands on festive occasions, which were intended to cover either the goiter itself or the scars after a goiter operation.
literature
- Lothar-Andreas Hotze, Petra-Maria Schumm-Draeger: Thyroid diseases. Diagnosis and therapy. BMV, Berlin 2003, ISBN 3-88040-002-4 .
- Wieland Meng: Thyroid Diseases. Pathophysiology - diagnostics - therapy; with 57 tables. G. Fischer, Jena 1992, ISBN 3-334-60392-X .
- Franz Merke: History and Iconography of Endemic Goiter and Cretinism. Bern u. a. 1971.
- Torsten Kuwert: Thyroid. In: Torsten Kuwert, Frank Grünwald , Uwe Haberkorn , Thomas Krause (eds.): Nuclear medicine. Georg Thieme Verlag, Stuttgart 2008, ISBN 978-3-13-118504-4 .
- J. Larry Jameson, Anthony P. Weetman (for the German edition: Jens Zimmermann and George Kahaly): Diseases of the thyroid. In: Manfred Dietel, Joachim Dudenhausen, Norbert Suttorp (eds.): Harrison's internal medicine. Mc-Graw-Hill, London, ABW Wiss. Verl. Berlin 2009, ISBN 3-936072-10-8 .
- Bronchocele. In: Johann Heinrich Zedler : Large complete universal lexicon of all sciences and arts . Volume 4, Leipzig 1733, column 1466-1468.
Web links
- Historical overview at schilddruesenguide.de
Individual evidence
- ↑ Entry Struma on duden.online.
- ↑ Ursus-Nikolaus Riede, Martin Werner, Hans-Eckart Schäfer (Ed.): General and special pathology. Thieme, Stuttgart 2004. p. 1014. ISBN 3-13-683305-8
- ↑ Lothar-Andreas Hotze, Petra-Maria Schumm-Draeger: Thyroid diseases. Diagnosis and therapy. Berlin 2003, ISBN 3-88040-002-4 , p. 152
- ↑ Outdated guidelines of the German Society for Pediatric Surgery: Struma ( Memento from March 31, 2008 in the Internet Archive )
- ^ R. Hörmann: Thyroid diseases . ABW-Wissenschaftsverlag, 4th edition 2005, pages 15–37. ISBN 3-936072-27-2
- ↑ Lothar-Andreas Hotze, Petra-Maria Schumm-Draeger: Thyroid diseases. Diagnosis and therapy. Berlin 2003, ISBN 3-88040-002-4 , p. 149
- ↑ Christoph Reiners et al: Prevalence of thyroid disorders in the working population of Germany . (PDF); accessed on May 8, 2017
- ↑ Lothar-Andreas Hotze, Petra-Maria Schumm-Draeger: Thyroid diseases. Diagnosis and therapy. Berlin 2003, ISBN 3-88040-002-4 , pp. 149ff
- ^ Dagmar Führer, Andreas Bockisch, Kurt Werner Schmid: Euthyroid goiter with and without nodes - diagnosis and therapy. In: Deutsches Ärzteblatt , 2012, 109 (29–30), pp. 506–516. doi: 10.3238 / arztebl.2012.050
- ↑ G. Heberer, L. Schweiberer: Indication for operation . Springer-Verlag, 2013, ISBN 978-3-642-87054-5 ( full text in the Google book search).
- ↑ R. Gärtner: Does iodine have an influence on the development and course of Hashimoto's thyroiditis? Iodine supply currently in 2007
- ↑ Federal Institute for Risk Assessment (PDF; 146 kB)
- ↑ Cheng-Tsai Liu, Liu Zheng-cai, Ka Hua: A Study of Daoist Acupuncture & Moxibustion . 1999, ISBN 1-891845-08-X , pp. 20-21
- ↑ Karl Sudhoff (Ed.): Theophrast von Hohenheim, called Paracelsus: All works. Dept. I: Medical, scientific and philosophical writings. 14 volumes, Munich and Berlin 1922–1933; here: Volume IV, pp. 222-225.
- ↑ Joseph S. Strebel (Ed.): Paracelsus: Complete Works. Sankt Gallen 1944–1949; here: Volume II, pp. 227-233.
- ↑ Paul Cranefield and Walter Federn: Paracelsus in goiter and cretinism: a translation and discussion of “De Struma, Vulgo Der Kropf”. In: Bulletin of the History of Medicine 37, 1963, pp. 463-471.
- ^ JS Strebel: Paracelsus on goiter and goiter development. In: Nova Acta Paracelsica 6, 1952, pp. 10-18.
- ^ Ernest Campbell Mossner: The Life of David Hume . 2nd Edition. Clarendon Press, Oxford 1980, ISBN 0-19-924336-0 , pp. 338 (English): ... as much as the Country is agreeable in its Wildness; as much are the Inhabitants savage & deform'd & monstrous in their appearance. Very many of them have ugly swelld Throats: Idiots, & Deaf People swarm in every Village; & the general aspect of the people is the most shocking I ever saw.
- ^ Isidor Greenwald: The history of goitre in the Netherlands. In: Janus 49, 1960, pp. 285-299.
- ^ Isidor Greenwald: Notes on the history of goitre and of thyrotoxicosis in Denmark. In: Centaurus 12, 1968, pp. 192-196.
- ^ Albert Faulconer, Thomas Edward Keys: Jean Baptiste André Dumas. In: Foundations of Anesthesiology. 2 volumes, Charles C Thomas, Springfield (Illinois) 1965, Volume 1, p. 459.
- ^ Otto Westphal , Theodor Wieland , Heinrich Huebschmann: life regulator. Of hormones, vitamins, ferments and other active ingredients. Societäts-Verlag, Frankfurt am Main 1941 (= Frankfurter Bücher. Research and Life. Volume 1), pp. 9–35 ( History of hormone research ), here: pp. 21–24 ( The thyroid ).
- ↑ Lutz Röhrich : Lexicon of the proverbial sayings. Freiburg 2006, ISBN 978-3-451-05400-6
- ^ Social Democratic Library, Volume 3 (1890)
- ↑ choker at planet-wissen.de
