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 The term goiter (from the Latin gutter = the throat) is used to describe generalizedenlargement of the thyroid gland.  A discrete swelling (nodule) in one lobe with no palpable abnormality elsewhere is termed an isolated (or solitary) swelling. Discrete swellings with evidence of abnormality elsewhere in the gland are termed dominant. Deficiency of circulating thyroid Iodine deficiency hormone due to the deficiency (Most common) of inborn errors of metabolism (Daily requirement: 0.10.15mg) 1. Very low iodide content in the water and food 2. Although iodides in food and water may be adequate, failure of intestinal absorption EXCESSIVE RELEASE OF THYROID STIMULATING HORMONE (TSH)  The natural history of simple goiter Stages in goiter formation are: • Persistent growth stimulation causes diffuse hyperplasia; all lobules are composed of active follicles and iodine uptake is Goitrogenic agents 1. The vegetables of the brassica family (cabbage, kale and rape), which contain thiocyanate 2. Drugs such as paraaminosalicylic acid (PAS) and the antithyroid drugs. 3. Consumption of iodine in large quantities Improper synthesis of thyroid and hormones Thiocyanates results in defective interfere with negativeperchlorates feedback mechanism to iodide trapping; carbimazole the anterior pituitary and thiouracil compounds interfere with the oxidation of iodide and the binding of iodine to tyrosine Hyperplasia represents the response of the thyroid to TSH, other growth factors, or circulating stimulatory antibodies. The hyperplasia may compensate for thyroid hormone deficiency. The epithelium is tall and columnar; the follicles are collapsed and contain only scanty colloid. When the hyperplastic stage is extreme and prolonged, there may be confusion with carcinoma because of the degree of cellularity and the presence of enlarged cells. The nuclei are enlarged, hyperchromatic, and even bizarre. Because of follicular collapse and epithelial hyperplasia and hypertrophy, papillary changes can be seen. uniform. This is a diffuse hyperplastic goiter, which may persist for a long time but is reversible if stimulation ceases. • Later, as a result of fluctuating stimulation, a mixed pattern develops with areas of active lobules and areas of inactive lobules. Thyroid follicles may not remain in a state of continuous hyperplasia, but instead undergo involution, with the hyperplastic follicles re-accumulating colloid. The epithelium becomes low cuboidal or flattened and resembles that of the normal gland. Some follicles become much larger than normal, contain excessive colloid, and are lined with flat epithelium. The gland is diffusely enlarged, soft, and has a glistening cut surface because of the excess of stored colloid. In addition to large follicles filled with colloid, there are foci in the gland where hyperplasia is still evident.This phase of nontoxic goiter is often termed colloid goiter. or rapid enlargement of a nodule raises suspicion of carcinoma but is usually due to hemorrhage into a simple nodule. and in their responsiveness to TSH. in their capacity for growth and function. necrosis. A painful nodule.  Most patients with multinodular goiter are asymptomatic and do not require operation. and persistence of regions of epithelial hyperplasia. or some form of partial resection. to conserve sufficient functioning thyroid tissue to subserve normal function while reducing the risk of hypoparathyroidism that accompanies total thyroidectomy.  Retrosternal extension with actual or incipient tracheal compression is also an indication for operation. and others will have relative colloid and/or iodide deficiency. may simulate carcinoma. The new follicles form nodules and may be heterogeneous in their appearance. a hyperplastic goiter may regress if thyroxine is given in a dose of 0. causing central necrosis and leaving only a surrounding rind of active follicles. inflammation. removing the bulk of the gland. .  Although the nodular stage of simple goiter is irreversible.  There is a choice of surgical treatment in multinodular goitre: total thyroidectomy with immediate and lifelong replacement of thyroxine. the nodules are palpable and often visible. leaving up to 8 g of relatively normal tissue in each remnant. more than half of benign nodules will regress in size over ten years.  Operation may be indicated on cosmetic grounds. Hardness and irregularity. and others that are well demarcated and resemble true adenomas. • Continual repetition of this process results in a nodular goiter. Thyroid function tests---.  Investigations 1.  Diagnosis Diagnosis is usually straightforward. and fibrosis. Patients with long-standing thyroid deficiency typically develop nodular goiters that result from over distention of some involuted follicles.2 mg daily for a few months. 5. they are smooth. Ultrasound and CT give more detailed images but rarely influence clinical management. sudden appearance. Differential diagnosis from autoimmune thyroiditis may be difficult and the two conditions frequently coexist. The patient is euthyroid. stimulation by Necrotic lobules coalesce to form nodules filled either with iodine-free colloid or a mass of new but inactive follicles. leading to hemorrhage. for pressure symptoms or in response to patient anxiety. due to calcification. usually firm and not hard. FNAC is only required for a dominant swelling in a generalized goiter. The vascular network is altered through the elongation and distortion of vessels.  Treatment  In the early stages. the presence of circulating thyroid antibodies tested to differentiate between autoimmune thyroiditis 3. Growth of goiters therefore may be related to focally excessive stimulation by TSH. Most nodules are inactive.15–0. some zones will contain larger-than-normal amounts of colloid and/or iodide. Plain radiographs of the chest and thoracic inlet will rapidly demonstrate clinically significant tracheal deviation or compression 4. and active follicles are present only in the internodular tissues. as is the presence of a dominant area of enlargement that may be neoplastic. and the goiter is painless and moves freely on swallowing.to exclude mild hyperthyroidism 2.  Subtotal thyroidectomy involves partial resection of each lobe.• Active lobules become more vascular and hyperplastic until hemorrhage occurs. These localized degenerative and reparative • changes produce some nodules that are poorly circumscribed. Because the nodules distort the vascular supply to some areas of the gland. for this reason. Reoperation for recurrent nodular goiter is more difficult and hazardous and. However. an increasing number of thyroid surgeons favor total thyroidectomy in younger patients. Total lobectomy and total thyroidectomy have the additional advantage of being therapeutic for incidental carcinomas . reoperation and completion total thyroidectomy is straightforward if required for progression of nodularity in the remaining lobe. particularly in older patients. with one lobe more significantly involved than the other. In these circumstances.   The technique is essentially the same as described for toxic goiter. total lobectomy on the more affected side is the appropriate management with either subtotal resection (Dunhill procedure) or no intervention on the less affected side. as are the postoperative complications. the causative factors persist and recurrence is likely. when the first operation comprised unilateral lobectomy alone for asymmetric goiter. In many cases. the multinodular change is asymmetrically distributed. however. More often.