Goitre

A goitre is an abnormal enlargement of the thyroid gland, presenting as a visible or palpable swelling at the base of the neck. Although the condition may occur with normal thyroid function, many cases accompany either hypothyroidism or hyperthyroidism. The majority of goitres are benign, but their presence can indicate underlying metabolic, autoimmune, or nutritional disorders. Historically widespread across regions with iodine-deficient soils, goitre has played a prominent role in the development of public health initiatives aimed at preventing thyroid diseases.

Clinical Presentation and Classification

Goitres vary significantly in size, appearance, and associated symptoms. In mild cases, the enlargement may be detectable only on palpation, whereas severe goitres can become visibly prominent and even extend below the sternum. When thyroid function is affected, clinical features reflect the underlying hormonal imbalance.
Hyperthyroidism commonly produces symptoms linked to adrenergic stimulation and heightened metabolic activity, including palpitations, tremors, heat intolerance, nervousness, tachycardia, and weight loss. In contrast, hypothyroidism leads to fatigue, cold intolerance, constipation, weight gain, and slowed metabolism. These symptoms are often non-specific, making diagnosis reliant on thyroid function tests.
The World Health Organization classifies goitre by palpation into three grades:

• Grade 0: no palpable or visible enlargement;
• Grade 1: palpable but not visible with the neck in a normal position;
• Grade 2: clearly visible swelling.

Causes and Risk Factors

Globally, iodine deficiency remains the most significant cause of goitre, responsible for the majority of cases. Iodine is essential for the synthesis of thyroid hormones, and inadequate intake leads to reduced hormone production and compensatory enlargement of the gland. Regions with low iodine levels in the soil, particularly mountainous areas affected by glaciation or erosion, have historically experienced high rates of endemic goitre.
Additional factors contributing to goitre include:

• Selenium deficiency, which impairs thyroid hormone metabolism;
• Autoimmune thyroiditis, particularly Hashimoto’s thyroiditis in iodine-sufficient regions;
• Exposure to dietary goitrogens, including toxic cyanide compounds in cassava-based diets;
• Genetic factors or familial thyroid disorders.

Types of Goitre

Goitres are categorised based on their structural characteristics.
Nodular goitre: This form involves the presence of one or more distinct nodules within the gland.

• Uninodular goitre may be inactive or autonomously hyperfunctioning (“toxic”).
• Multinodular goitre is the most common thyroid disorder, comprising multiple nodules that grow at varying rates. Toxic multinodular goitre involves excessive autonomous production of thyroid hormones. Although most nodules are benign, a small proportion may represent malignancy, typically identified during surgical evaluation.

Diffuse goitre: Here, the entire gland is uniformly enlarged due to generalised hyperplasia. Diffuse enlargement can accompany autoimmune disorders or hormonal dysregulation and may present alongside metabolic symptoms.
Size-based classifications also exist, ranging from mild, barely detectable enlargement to very large retrosternal swellings capable of compressing adjacent structures.

Diagnosis

Evaluation of a suspected goitre involves a combination of clinical examination and biochemical testing. Blood tests measuring levels of thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3) provide essential information on gland function. Imaging techniques, such as ultrasound, assist in differentiating between diffuse and nodular enlargement and in assessing structural abnormalities, such as cysts or suspicious nodules.

Treatment Approaches

Management depends on the underlying cause, severity, and functional status of the thyroid gland.

• Iodine supplementation: Small doses of iodine or potassium iodide are administered when deficiency is identified. Public health strategies centre on iodised salt, a widely implemented preventive measure.
• Radioactive iodine therapy: Used when the gland produces excessive hormone, this method reduces gland size and activity.
• Thyroid hormone replacement: Indicated for hypothyroid-associated goitres, restoring normal hormone levels and reducing TSH-driven enlargement.
• Surgical intervention: Partial or total thyroidectomy may be required for large goitres causing compression, for cosmetic reasons, or when malignancy is suspected.

Historical and Medical Developments

The recognition of iodine’s role in thyroid physiology marked a turning point in understanding goitre. Early observations by physicians in China during the Tang dynasty describe treatments using iodine-rich animal thyroid tissue and seaweeds. Medieval Islamic scholars later detailed conditions resembling hyperthyroid goitre, including the association with exophthalmos.
In the modern era, iodised salt programmes introduced during the early twentieth century drastically reduced goitre prevalence in many regions. This public health measure exemplifies an effective nutritional intervention. Prior to these initiatives, goitre was widespread in areas such as the Alps, the Himalayas, and parts of North America, where erosion processes depleted soil iodine.
Medical history records several descriptions of goitre-related disorders. The condition later known as Graves’ disease was recognised in different cultural contexts before being named in the nineteenth century. Clinical advances in endocrinology and the discovery of iodine in seaweed ash in 1811 further transformed understanding and treatment.

Epidemiology and Cultural Context

Goitre remains more common in women, largely due to autoimmune causes. Although now rare in many developed countries, it continues to affect populations in parts of India, China, Central Asia, and sub-Saharan Africa where iodine intake remains insufficient. The condition has also manifested in domestic animals in iodine-depleted landscapes.
Cultural responses to goitre have varied widely. In some Alpine communities, visibly enlarged necks became normalised and even regarded as attractive. In others, individuals faced stigma, prompting adaptations such as decorative chokers designed to conceal swellings. Misconceptions persisted historically, including the belief that wearing bottles of iodine around the neck could prevent the condition.
The symbolic presence of goitre extends into heraldry; some family crests feature figures with enlarged necks as linguistic or visual puns.