A goiter is a swelling in the neck caused by an enlarged thyroid gland. Some goiters appear as small bulges, while others are large, protuberant, and may even extend into the chest.

Goiters are more likely to develop in women than men, and they are more common among people over 40. Most goiters are not painful, but larger goiters may cause neck discomfort, as well as other symptoms related to the compression of adjacent structures. It is important to note that a goiter is often a non-cancerous condition. However, a person with a lump in their neck should see a doctor to rule out a thyroid goiter and explore the need for additional workup.

Treatment options are available that may reduce the swelling associated with goiter, minimize or eliminate the unpleasant symptoms, and improve a person’s physical appearance.

“While most goiters are relatively small and do not pose problems, they may be indicative of an underlying functional thyroid abnormality,” says Yale Medicine endocrinologist Kavya Mekala, MD. “It is important that a goiter be evaluated by a qualified health care professional, who may consider referral to a thyroid specialist, so that further investigations may be undertaken for the appropriate diagnosis and management of the condition.”

A goiter is an enlarged, swollen thyroid gland.

The butterfly-shaped thyroid gland uses iodine from food, which is transported from the gastrointestinal (GI) tract to the thyroid through the bloodstream, to create thyroid hormones thyroxine (T4) and triiodothyronine (T3). The primary role of the thyroid gland is to regulate metabolism. It helps maintain bodily functions—for example, skin and hair growth, as well as temperature regulation. In children, it promotes growth and development. The thyroid secretes higher or lower levels of hormones depending on the body’s needs, as dictated by the pituitary gland, which releases its own hormone, called thyroid-stimulating hormone (TSH).

There are several possible causes of goiter, including:

• An iodine deficiency
• An overactive or underactive thyroid
• Thyroid nodules
• Thyroid infection or injury
• Inflammation of the thyroid (thyroiditis)
• Exposure to radiation
• Certain inherited conditions
• Graves’ disease
• Hashimoto’s disease
• Cancer

Sometimes, the thyroid is unable to make enough thyroid hormone to meet a person’s needs. When this happens, the thyroid itself may increase in size to compensate for the deficiency. Those with iodine-deficient diets are at greater risk of developing a goiter. However, because iodine is added to table salt here in the United States, few people in this country experience iodine deficiency.

Pregnancy often causes mild swelling of the thyroid gland to meet increasing metabolic demands, and it typically resolves after delivery.

Certain medications, such as birth control pills, amiodarone (a treatment for heart arrhythmia), and lithium (a treatment for bipolar disorder), may increase the chances of thyroid enlargement.

Graves’ disease and Hashimoto’s thyroiditis are both autoimmune thyroid conditions where antibodies attack the thyroid, causing inflammation and thyroid enlargement. Sometimes, a baby who is born to a woman with Graves’ disease may be born with a congenital goiter. This may happen because of maternal antibodies that may be passed along to the child in utero or because of medications the mother takes that may cross the placenta.

Goiter typically presents as a swelling in the lower portion of the front of the neck. The swelling may be smooth or irregular, large or small, tender or painless, and symmetrical or larger on one side. It usually isn’t a painful condition, but it may cause discomfort, particularly when the goiter is large.

Other symptoms may include:

• Difficulty swallowing
• Choking sensation
• Voice hoarseness
• Coughing
• Noisy breathing
• Trouble breathing
• Snoring
• Neck veins that bulge
• Dizziness

Symptoms that may accompany a goitrous swelling caused by hyperthyroidism (overactive thyroid) include:

• Anxiety or nervousness
• Weight loss
• Diarrhea
• Fatigue
• Shakiness
• Weakness
• Fast or irregular heartbeat
• Feeling winded from physical activity
• Irregular menstrual cycles
• Sleep problems
• Feeling sweaty or heat intolerance

Symptoms that may accompany a goitrous condition caused by hypothyroidism (underactive thyroid) include:

• Depression
• Weight gain
• Constipation
• Dry skin, hair and/or nails
• Irregular menstrual cycles
• Fatigue
• Feeling cold
• Memory or concentration problems

• Female sex
• Age 40 or older
• Family history of goiter
• Prior radiation exposure to neck (especially if in childhood)
• Low-iodine diet
• Exposure to endocrine-disrupting chemicals or goitrogens
• Smoking

A physician can confirm the diagnosis of goiter after obtaining a patient’s medical history, performing a physical exam, and through laboratory investigations and imaging studies.

Relevant medical history questions include a family history of thyroid disease; dietary history, including iodine intake; pregnancy history (in women); history of tobacco use, and history of exposure to radiation.

During a physical exam, a provider will perform a detailed neck evaluation, including inspection for a visible swelling and palpation (or feeling the neck) to assess the size, texture, and other characteristics of the lump. If the goiter is particularly large, the patient may also be asked to raise their hands above their head for 2 or 3 minutes to elicit any compressive symptoms.

The following tests may be used to confirm a goiter diagnosis:

• Blood tests to assess thyroid hormone function. If the physician suspects that a goiter has been caused by autoimmune thyroid disease, they may also recommend antibody testing.
• A thyroid scan (scintigraphy), which is a nuclear medicine test. To prepare for the test, a patient is asked to ingest a small amount of radioactive iodine, which is absorbed by the thyroid, allowing the assessment of thyroid gland function.
• An ultrasound, which allows doctors to view the thyroid. Based on findings such as the presence of nodules, further assessment with a fine-needle aspiration biopsy may be advised.
• A CT scan may be recommended to assess for extension of the goiter into the chest cavity.

Most simple goiters, especially when small, do not need any therapy, although periodic assessment may be advised, in case future treatment is needed. In some instances, the goiter may resolve spontaneously.

In other situations, patients may be recommended any of the following options:

• Radioactive iodine. When the thyroid produces too much hormone, radioactive iodine can help to shrink the thyroid, significantly reducing the size of goiter. Radioactive iodine treatments are not safe for women who are pregnant or breastfeeding, and they are not recommended for women who may plan to become pregnant within 6 months after therapy. Radioactive iodine has a high likelihood of causing permanent thyroid hormone deficiency, therefore requiring the patient to be on life-long thyroid hormone replacement therapy.
  
• Surgery. Surgery may be recommended to remove a part or all of the thyroid gland when a goiter has become large enough to cause symptoms that reduce quality of life, such as breathing problems or swallowing difficulties. Surgery is usually the preferred treatment when there are no underlying thyroid functional abnormalities accompanying the goiter. Because removing the entire thyroid gland will cause permanent hypothyroidism, those patients will need to be on life-long thyroid hormone replacement therapy.
  
• Medication. If a person has a goiter because their body doesn’t produce enough thyroid hormone, their doctor may prescribe thyroid hormone supplementation if there is underlying iodine deficiency. If a goiter is caused by inflammation, a doctor may prescribe anti-inflammatory medications or steroids. When a person has an overactive thyroid due to Graves’ disease, they may be prescribed anti-thyroid medications (methimazole, or propylthiouracil) to reduce the amount of hormone that the thyroid produces.

Most goiters can be treated successfully, helping people resolve their symptoms and improve their appearance, as well as their quality of life. It is important that a goiter be recognized early so that any potentially reversible causes may be addressed.

“At the Smilow Endocrine Neoplasia Center and other Yale network locations, we have a multidisciplinary team of highly trained specialists, including endocrinologists, thyroid surgeons and nuclear medicine specialists, who provide comprehensive care for the management of goiter and associated diagnoses,” says Dr. Mekala.