Goiter Differential Diagnosis Table

Goiter Differential Diagnosis Table:

Goiter is a lump that appears in the front of the neck, either from a thyroid enlargement or from cell overgrowth that forms nodules in the thyroid. It can either lead to elevation or decrease in thyroid hormone, but in most cases, it doesn’t affect thyroid function; non-toxic goiter.
The main symptom of goiter is swelling in the neck, and most patients don’t recognize the disease until swelling appears.
Goiter treatment varies from pharmacological treatment to surgical excision of nodules or maybe all of the thyroid gland; in some cases, if these nodules or enlargement don’t affect the thyroid or its function, treatment may not be required.
Diagnosis of goiter initially begins with a physical examination, where the doctor can examine the swelling in the neck; further investigation, mainly by ultrasound, can confirm the disease.

How to Distinguish Goiter from Other Diseases

Distinguish Graves’ Disease from Goiter – Diagnosis

Graves disease is an autoimmune disorder that makes the body attack the thyroid gland, making the thyroid gland produce more thyroid hormone, giving symptoms and manifestation of hyperthyroidism. Sometimes the enlargement can lead to goiter itself.

• The most specific test for the diagnosis of Graves’ disease is Thyrotropin Receptor Antibody (TRAb); the presence of this antibody usually confirms Graves with no additional test needed.
• Thyroid function tests; low TSH, High T3, and T4 are indications of hyperthyroidism, which is the main clinical manifestation for Graves’ disease.
• Increasing Thyroid Peroxidase Antibodies (TPOAb) can’t confirm Graves disease since it’s indicative more of the presence of autoimmune disease, which will make it positive also in Hashimoto’s disease.

Distinguish Thyroid Nodule Disease from Goiter – Diagnosis

Thyroid nodules are often benign lumps in the thyroid gland at the front of the neck; they are very common, and sometimes they are overgrowths of cells, cysts, inflammation, and rarely tumors.

• Thyroid ultrasound can easily detect and diagnose thyroid nodules.
• Fine needle aspiration (biopsy) is needed to confirm the benign growth of these nodules and rule out malignancy.

“Thyroid nodules and goiter may look alike when it comes to neck swelling, but the main difference is that goiter is an enlargement of thyroid tissue itself, where thyroid nodule may be solid or fluid cysts.”

Distinguish Substernal Goiter Disease from Goiter – Diagnosis

Substernal goiter is the growth of the thyroid gland downward in the thoracic inlet inside the upper chest; this usually happens very slowly, and growth occurs over years. Most problems of substernal goiter come from difficulty in swallowing and later on may be difficulty in breathing due to compression on the trachea and esophagus. The only treatment for substernal goiter is surgical removal.

• Diagnosis of substernal goiter is mainly by CT chest or MRI, which will show mediastinal mass and any compression on the trachea and esophagus; it will help in knowing the extent and depth of growth for surgical removal too.
• Routine thyroid function test to know if thyroid function has been affected by goiter.
• Ultrasound with fine needle biopsy is indicated only if there’s a mass inside the thyroid, which may indicate malignancy.

Distinguish Thyroiditis Disease from Goiter – Diagnosis

Thyroiditis is an inflammation of the thyroid gland; it has many causes, some are acute from viral, bacterial infection, or maybe drug-induced, and some are chronic like Hashimoto’s, which is the most common cause of thyroiditis. According to the underlying condition, the thyroid gland can be affected either by elevation or decrease in thyroid function. In some cases, inflammation of thyroid cells can lead to permanent damage to the thyroid gland.
Since thyroiditis develops from different underlying causes, a lot of different diagnostic tests are needed:

• Physical examination by examining the thyroid itself is the initial step in diagnosis.
• Thyroid function test to see if thyroiditis resulted in hypo or hyperthyroidism.
• Radioactive iodine uptake to determine the thyroid’s ability to absorb iodine.
• Rarely, if the diagnosis is not confirmed, Fine needle aspiration biopsy is needed to look for malignancies.
• Ultrasound of the thyroid gland, which will appear hypoechoic.

Distinguish Hashimoto’s Thyroiditis Disease from Goiter – Diagnosis

Hashimoto’s disease is an autoimmune disorder when the body attacks the thyroid gland causing symptoms of hypothyroidism. In some rare cases, hyperthyroidism may occur. In symptomatic manifestation of hypothyroidism, treatment with medication is needed. Treatment may also relieve goiter as it may occur from Hashimoto’s itself.

• Thyroid peroxidase antibodies (TPOAb) are the main diagnostic test in Hashimoto’s disease; almost all patients will be positive for the presence of the antibody in their blood.
• Thyroglobulin antibodies will be positive in Hashimoto’s disease but will also be positive in other autoimmune disorders like Graves’.
• Thyroid function test is routinely made to see if the disease affected thyroid function; it will usually show High TSH, low T4, and low T3.
• Ultrasound of the thyroid gland can help in diagnosis if there’s a goiter formation or any enlargement in the thyroid gland.

Distinguish Subacute Thyroiditis Disease from Goiter – Diagnosis

Subacute thyroiditis is an inflammation in the thyroid gland usually happening after viral or bacterial infection. This often resolves within one month on its own and with some anti-inflammatory medication. It causes neck pain, swelling, and tenderness on touch.
Several diagnostic tests are needed along with patient history to confirm the diagnosis.

• Radioactive iodine uptake is usually very weak due to the inability of the thyroid gland to absorb it.
• Thyroid function tests will show first low TSH and High T4 and T3 indicating hyperthyroidism, but after a while, T3 and T4 will decrease and TSH will increase, showing a sign of hypothyroidism.
• Fine needle aspiration will be needed only if the diagnosis is unclear and confirmation is needed.
• Routine inflammatory tests like increased CRP and ESR will be done to monitor progression of disease and response to treatment.

Distinguish Thyroid Cancer Disease from Goiter – Diagnosis

Thyroid cancer is the malignant growth of cells inside the thyroid, thyroid cancer survival rate is very high, and it’s treatable with medication or surgical removal of the gland or both. In most cases, thyroid cancer is detected incidentally by neck palpitation or the presence of lumps in the neck, but other than that, it’s mostly asymptomatic.

• Thyroid ultrasound to detect any nodules or enlargement presence is the initial diagnostic step in thyroid cancer.
• Fine needle aspiration is the confirmative test for the presence of malignancy.
• Radioactive iodine intake is a simple process where the patient ingests radioactive iodine, where the tissues that absorbed the iodine are usually malignant.
• Thyroid function test is routinely tested to make sure whether the cancer affected the gland or not.

“MRI and PET scan are needed after confirmation of thyroid cancer to confirm or rule out metastasis.”

Distinguish Thyroid lymphoma Disease from Goiter – Diagnosis

Thyroid lymphoma is a very rare type of lymphoma; the lymphatic cells inside the thyroid gland become cancerous. This type of lymphoma tends to progress very rapidly over a few weeks. It causes neck swelling and difficulty swallowing and may cause dyspnea.

• Thyroid function test to evaluate hypothyroidism that may be caused by thyroid lymphoma.
• Fine needle aspiration to confirm and detect malignancy and confirm the presence of lymphoid cells.
• Ultrasound to check for thyroid enlargement and maybe lymph nodes of the thyroid.
• Lymphoma markers such as CD marker and LDH can help in differential diagnosis.

Important Red Flags in Goiter

Goiter itself as a disease is a slow-growing lump in the neck that is usually harmless. But since most of the above-mentioned diseases have similar symptoms, medical attention and diagnostic tests are needed.
A rapid growth in goiter (neck swelling) is unusual and may reflect underlying conditions like Graves’, thyroid cancer, or thyroid lymphoma.
Difficulty in swallowing (dysphagia) occurs commonly when goiter is large, but this may progress to difficulty breathing and hoarseness of the voice, which indicates the lump is compressing the trachea.