Doctor Thein Hlaing
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GOITRE

GOITRE

3.1       WHAT IS GOITRE?

Abnormal enlargement of the thyroid gland is known as goitre.

Often when the thyroid functions improperly, the result is goitre.

Usually the gland swells and the increased size is noticeable in the neck,but the thyroid disturbances are not necessarily accompanied by swelling.

Goitre in other words, is not a disease.

Until now causes of endemic goiter has not been completely determined.

Goitre never endangers the life of a person unless it gets complicates.

When you make a list of human diseases it will never be completed unless you mention the word of goitre.

Thus goitre or enlargement of the thyroid gland is the end result of improper function.

Goitre occours with varying intensity in almost every country only a few countries appear to be entirely free from it. Therefore goitre may occur in any locality, in any race, in any person, at any age, even in a new born baby.

Since it is found in every part of the world, it could mention that there is a goitre belt around the world.

If a simple goitre does not appear during childhood or adolescence it is sure for it to make its first appearance in adult males,but it is not at all uncommon for this to happen to women during pregnancy and location.

3.2       TYPES OF GOITRE

3.2.1    1. CONGENITAL GOITRE

In endemic areas the thyroid gland in the newborn baby is in the diffuse hyperplastic phase with well conserved lobules, though the number of follicles is increased, they contain no colloid. The connective tissue is congested and hyperemia may be so intense as to cause dyspnoea and endanger the baby’s life immediately after birth. Such cases are seen in highly endemic areas as Northen Shan States.

Injection lipoidol 1cc stat as soon as possible. i.e. immediately after birth will safe the baby from asphysiated death.

To prevent congenital goitre you can also give 1cc of lipoidol injection to pregnant lady.

Figures: Congenital Goitre Photos

3.2.2    2. PUBERTY GOITRE ( PUBERTAL GOITRE )

In childhood the thyroid grows in size until the baby or girl is sexually matured.

When once they are sexually matured the goitre may regress in growth or if not it may stop for its enlargement.

Colloid goitre being physiological, it is smooth, soft, uniform and adds the beauty of a girl.

Figures: Puberty Goitre (Pubertal Goitre) Photos

3.2.3    3. ADOLESCENT GOITRE

Puberty is a critical time for the thyroid and many cases of goitre known as adolescent goitre occur at that time.

The size or enlargement of the thyroid gland is also influenced by sexual disturbances.

It may become larger during menstruation and pregnancy.

It may also become larger in women following a number of childbirths close upon each other.

On the otherhand, a deficiency of thyroid influences the sex organs may lead to sterility.

Clinically the adolescent goitre could be classified or categorized by the following classification,

3.2.3.1 ( A ) INVISIBLE GOITRE

Could not be seen for its enlargement but could be felt for its presence. Palpable not visible.

3.2.3.2 ( B-i ) VISIBLE GOITRE TYPE I Survey Type

Palpable not visible in normal position. It could be easily seen when neck is fully extended and when ask to deglutade or swallow.

3.2.3.3 ( B-ii ) VISIBLE GOITRE TYPE II

Presence of enlarged goitre is easily seen and noticed at closed range in a normal positon i.e. without extension of the neck.

3.2.3.4 ( B-iii ) HUGE GOITRE

Occupying the whole neck seen from distance.

3.2.3.5 ( B- iv ) GIGANTIC OR MONSTROUS TYPE

Huge goitre, solitary adenoma or nodular not only occupying but protruding anteriorly and also lateralward.

Figures: Adolescent Goitre Photos

3.2.4.   4. TOXIC GOITRE

3.2.4.1 ( A ) PRIMARY TOXIC GOITRE

. Common, prevalence in sporadic area rare in endemic area.

. Eye – exopthalmos ++

. Tremors – present

. Heartbeat – increased (tachycardia)

. Goitre not seen

. Nervousness +

. Irritable +

. Loss of weight +

3.2.4.2 ( B ) SECONDARY TOXIC GOITRE

. Goitre +

. Eye – exopthalmos +

. Tremor +

. Loss of weight

. Tachycardia

3.2.5    5. MALIGNANT GOITRE (CARCENOMA THYROID)

May be solitary adenoma or nodular

Simple adenomas, solitary are pre cancerous in nature or bound to change into malignancy.

If you notice single solitary prominent adenomas in 5 persons in one locality in one day, that locality is said to be highly endemic and necessary preventive measures to be taken by health authorities.


Figures: Malignant Goitre (Carcenoma Thyroid)

3.3 PREVALANCE OF GOITRE

Goitre has probably afflicted people since the beginning of human race. Goitre is found in every part of the world with the exception of a few countries free of goitre.

When higher percentage of the people suffers from goitre, such as section of that area is known as endemic goitre area.

However, many cases of goiters are found outside the so called endemic area, than such goiter is know as sporadic goitre.

Sporadic goiters are prome to become toxic goiter while endemic goiters have less chance.

The reasons being endemic goitres are subthyroid in nature and is also its activity is subthyroid therefore rare to see or have toxic goitre.

A simple goitre no matter big or small seldom gives any trouble itself, unless it becomes so large and heavy as to disturb or exert pressure symptoms such as difficulty in breathing and swallowing.

They cannot be persuaded to undergo operation for its removal because it never endanger their life and asymptomatic except that it looks ugly and heavy.

3.4 PREVALANCE OF GOITRE IN MYANMAR

Goitre is prevalent in the mountainous parts of Myanmar especially in Chin Hills in the west, the Kachin Hill in the north, the Shan States on the east.

Also in Naga land in upper chindwin and nearer to eastern Assam.

The disease is common among children than among adults but the adult goiters are much larger and frequently give rise to pressure symptoms.

The incidence is higher in females than in males and is always greatest at puberty and pregnancy. On the North, and east where Myanmar abuts on China goitre rates are exceedingly high in Myitkyina area also around Bhamo, Namkham, Lashio etc.

It is also high in Pegu Division especially Phyu, Kyauk-kyi, Thaung goo, Thandaung, Mone, and villages in Pegu Yoma area.

Irrawaddy Division ( Bassein Division ) low land area, is not spare from endemicity and high incidence is noticed in Ahthauk, Engmai, Ah Phauk, Kyaung Gone, Ye Kyi, Kone Pyaw, Hinthada, Ngathaing Khaung, Bassein, Nga Pu Daw, Pyin Kha Yaing, Pantanaw, Myaung Mya, Ma Oo pin, Pharpone.

Though it is not hilly region this low land seem to be high in its endemicity because of frequent flooding and intense glaciation.

3.5 TREATMENT OF GOITRE

There is no drug for treatment of goitre. Iodine has been used in the treatment of goitre much longer than for its prevention.

Success in treatment and prevention of endemic goitre depends upon a thorough knowledge of its etiology.

The cause of endemic goitre has not been completely determined. A permanent falling off in thyroid function or activity results in hypertrophy and ends up with enlarged gland-goitre.

The etiology of endemic goitre involves many factors, iodine deficiency in the diet plays an important part in most cases but it cannot be taken as certain that it is the primary cause of goitre.

Therefore when once a goitre, always a goitre, treatment with iodine may produce involution with deposition of colloid but the gland does not revert completely to normal.

Goitre regressed within a few weeks of the administration of iodine but some patients developed further enlargement of the goitre during treatment.

After mid 18th century people stop short and fail to continue the research to find the actual cause of goitre.

They unanimously agree that protein bound iodine takes a major role in goitre.

Therefore nobody knows the actual cause of goitre until now. If you know the actual cause of goitre, it is definitely sure that goitre would be wiped out of the human list of diseases in no time, effectively, economically and successfully and there won’t be goitre in the world, because it is due to some deficiency and not bacterial in origin.

Therefore surgery is the only procedure to remove the goitre and thus it is the only effective treatment for goitre and its complications.

3.7 TOO MUCH IODINE

Thousands of persons are injuring their thyroid glands by the self administration of iodine in a mistaken belief that it is a cure for goitre and derangements of the gland.

So widespread is this fallacy that when a swelling appears on a persons neck his or her friends immediately say , ”Why don’t you take some iodine for that”.

Some may urge a grain or more of sodium iodide every day, other will advise a drop of tincture iodine in a glass of water daily.

It is unfortunate that this misunderstanding about the relation of iodine to thyroid gland and goitre should exist, for iodine under certain conditions may have great value in the prevention of goitre, especially in those districts of the world where the condition is endemic.

A person who indiscriminately doses himself with iodine is playing with dynamite.

The history of thousands of toxic goitres show that they started first as simple, innocuous swelling .Dosage with iodine was inaugurated and toxicity of the gland soon developed.

The thyroid gland often sets like a sponge in absorbing iodine when introduced into the system. The unnatural sequisition of iodine by the gland may throw it completely out of balance.

In certain sections of the world where goitre is endemic and there is a deficiency of iodine in the soil and water the administration of iodine in small amounts to growing children reduces the prevalence of goitre.

Even in goitrous districts the use of iodine as a preventive must be done with caution.

The human body shows a very wide range of variation in its tolerance to iodine. Some persons may take considerable quantities of iodine into their bodies without any apparent ill consequences. Other persons used ,but a small amount of iodine to make their thyroid speeded like a race horse.

As a preventive of endemic goitre iodine is directly of value. Goitre and thyroid disturbances are not caused entirely by a lack of iodine. It was pointed out that infected water, defective calcium metabolism and other factors may play an important role.

On combating adverse conditions in other parts of the body a thyroid might be encountering difficulty in keeping under control the iodine already in it. Hence the introduction of more iodine into systems might lead to a serious disturbance of the gland.

Any man, woman, or a child before taking iodine, should have a thorough medical examination that includes determination of the pulse, blood pressure ,and basal metabolic rate.

The taking of iodine is much more serious matter than taking of laxative.

Too much iodine in the body is highly poisonous. Goitre in adults cannot be cure with the iodine .If a non toxic goitre is so large as to mar one’ beauty, the only way that it can be safely reduced is by a surgical operation.

Most goitres in adult life are hard and nodular. When non toxic they carry on their functions in normal balance .The formation of nodules or benign tumor in the gland may be natural way of combating adverse conditions in the gland. The nodes may neutralize the activity of part of cells, or bring about stability in other ways .A gland might have as ample supply of iodine,yet goitre exist.

When we named such goitres simple because they are quiescent, they applied a misnomer to the simple goitres in children or adults are not simple at all, as many self medicative in the identity have found out to their sorrow. They are simple only as long as they are left undisturbed by the dosage with iodine.

Too much iodine is bad for any person, well or sick and a very, very small amount may be too much iodine for a person suffering from toxic goitre.

The first effect of iodine dosage may seen to convert the thyroid gland into a peaceful lamb, but it is not long before that false quiescence wears off and the gland becomes as enraged lion.

Its action is often very deceptive .Even in the most severe cases of hyperthyroidism, galloping goitre, the taking of considerable amounts of iodine for a week or two often causes a temporary lessening of tremor and a steadying of the heart. But in a short time the apparent benefits of the iodine dosage vanish and the sufferer soon relapses into a condition worse than before. Thus iodine though seems to be is the only cause of the disease, it is a preventive and not a cure for it.

It has been found that ,certain types of goitre that occur in childhood because of deficiency of iodine ,the number cases in any one district may often be sharply reduced by iodine prophylaxis. Thus the use of iodine is very small amounts is often recommended in the so called goitre belts, and such practice has in general been followed by reduction in incidence of endemic goitre. It may truly be said that in sections where the soil and the water contain insufficient iodine, simple endemic goitre has been concered. But when the thyroid gland has become enlarged and has an abnormal cellular structure, iodine will neither reduce it nor bring its functioning back to normal.

Dosage with iodine may cause growth to become larger instead of shrinking it and may step up the action of the gland to such a degree as to produce toxicity. Iodine prophylaxis is meeting with considerable success in reducing the incidence of the endemic disease in goitrous distri cts.

According to Dr.B.Bircher, who has analyzed the goitre statistics of several cases in Switzerland following the introduction of iodized salt in 1922, such general iodine prophylaxis has brought about a very marked in toxic goitrres. Hence, while iodine prophylaxis may prevent thyroid enlargement in childhood it may also foster increased thyroid activity in the community.

If you notice single solitary prominent adenomas in 5 persons in one locality in one day, that locality is said to be highly endemic and necessary preventive measures to be taken by health authorities.

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