Thyroid enlargement, also known as goiter when visibly swollen in the front of the neck, can result from inflammation, physiologic changes, iodine deficiency, thyroid tumors, or drugs. Enlargement may cause hyperfunction (thyrotoxicosis) or hypofunction (hypothyroidism), depending on the underlying cause. If not associated with infection, thyroid enlargement usually progresses slowly and progressively.

History and Physical Examination

History

• Family history of thyroid disease

• Onset and duration of thyroid enlargement

• Previous irradiation of thyroid or neck

• Recent infections

• Use of thyroid replacement therapy or goitrogenic drugs

Physical Examination

1. Inspect the trachea for midline deviation.

2. Palpate the thyroid gland while standing behind the patient:

   • Have the patient slightly extend the neck and swallow water.

   • Place fingers below cricoid cartilage and lateral to the trachea; palpate lateral lobes and isthmus.

3. Note the size, shape, consistency, nodules, and presence of a bruit over the lateral lobes using the bell of a stethoscope.

Medical causes of Thyroid enlargement

Special considerations

• Diagnostic tests: Needle aspiration, ultrasound, radioactive thyroid scan

• Surgical / therapeutic support: Prepare patient for surgery or radiation therapy

• Hypothyroid care: Warm environment, moisturize skin, laxatives for constipation, high-bulk low-calorie diet, encourage activity

• Hyperthyroid monitoring: Watch for restlessness, excessive sweating, weight loss

• Post-thyroidectomy care:

  • Monitor vitals every 15–30 min

  • Watch for tetany (Chvostek/Trousseau signs)

  • Monitor serum calcium, airway patency, bleeding

  • Keep tracheotomy equipment available

For thyroiditis:

• Administer antibiotics if bacterial

• Monitor for fever, neck swelling, hyperthyroidism signs

• Provide liquid diet if swallowing is difficult

Patient counseling

• Educate about signs of hypothyroidism and hyperthyroidism

• Explain thyroid hormone replacement therapy and potential overdose symptoms

• Discuss posttreatment precautions and radioactive iodine therapy if indicated

Pediatric pointers

• Congenital goiter (infantile myxedema or cretinism): mental retardation, growth failure, hypothyroid signs

• Early treatment prevents permanent mental deficits

• Genetic counseling is important for families with a history of thyroid disorders

References

1. Berkowitz, C. D. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. American Academy of Pediatrics; 2012.

2. Buttaro, T. M., Tybulski, J., Bailey, P. P., Sandberg-Cook, J. Primary Care: A Collaborative Practice. Mosby Elsevier; 2008.

3. Sommers, M. S., Brunner, L. S. Pocket Diseases. F.A. Davis; 2012.