NODULAR GOITRE
The commonest variety of goitre .
Pathology:
· Nodular goitre is the result of irregular involution
· Stress induce hyperplasia. Some follicles remains in hyperplasia.
· Others shows hyperinvolution. Fibrous tissues condensated in between.
· Fibrous tissues separate the gland into nodules so that the gland presents
a with irregular surface.

Aetiology:There are some predisposing factors:
1- Iodine deficiency:those living away from the sea e.g. oases & mountains.
2- Increase tissue demands: Stress conditions e.g. pregnancy, puberty & fever.
3- Goitrogens:
a- Some foods containing cyanates e.g. cabbage & cauliflower block the thyroid trap for iodine.
b- Some drugs e.g. anti thyroid and sulfur containing drugs .
4- Thyro trophic hormone: Imbalance in the thyroid pituitary balance .
5- Genetic factor:
· Autosomal, non sex linked, not fully recessive gene defect causes defect in enzyme system necessary for thyroxin formation. Low thyroxin level stimulate T.S.H release which cause goitre.
Clinical picture:
Usually female around the age of 35.
Neck swelling variable in size and not symmetrical.
Surface is nodular.
The consistency is variable, " Soft or firm ".
If there is solitary nodule the commonest site is the junction of the isthmus with one lobe.
Although it appears solitary, small adenomata are always present around.

Differential Diagnosis: Between solitary nodule and thyroid adenoma
Solitary (colloid adenoma)
True "foetal" adenoma
- common
- Actually not solitary
- Poor encapsulation
- Similar in structure to adjacent tissues
- No compression of the adjacent gland
-Rare
- Solitary
- Good encapsulation
- Different from adjacent tissues
-Causin compression of the adjacent gland
Treatment:
· Hemithyroidectomy: If solitary; remove the isthmus with the nearby lobe subtotal thyroidectomy is the operation of choice.
Complications:
1- Toxic change giving 2ry toxic goiter.
2- Malignant change in 4:8% of cases more with solitary nodule.
3- Calcification giving hard nodules." suspecious of malignancy".
4- Pressure effects when large or retrosternal
5- Hemorrhage into a cyst gives severe pain and may lead to suffocation so, urgent aspiration of the bloody content is needed while preparing for urgent thyroidectomy.
6- Tracheomalacia: Loss of the rigidity of the trachial rings due to prolonged compression. The trachea maintained patent

Normal follicle Relative or absolute Iodine deficiency ? Hyperplastic follicle


Physiological goitre
When the period of Stress is over
Normal Involuted follicle or Irregular involuted follicles or Hyperinvoluted follicle



Nodular goiter Colloid goitre

SOURCE: Prof. AYMAN SALEM'S BOOK
Copyright: Vascular Society of Egypt (Vascular Society of Egypt ) &Medical Educational web (Medical Educational web)
Not to be reproduced without permission of Vascular Society of Egypt