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NEUROENDOCRINOLOGY LETTERS (NEL)
including Psychoneuroimmunology, Neuro
psychopharmacology,
Reproductive Medicine, Chronobiology
and Human Ethology
ISSN 0172–780X

NEL Vol.23 No.4, August 2002

REVIEW ARTICLE
The goitre classification and management

2002; 23:351–355
pii: NEL230402R04
PMID: 12195240

Free full text online pdf [108 kb]
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The problem of goitre with particular consideration of goitre resulting from iodine deficiency (I):
Classification, diagnostics and treatment

Andrzej Lewinski

Department of Thyroidology, Institute of Endocrinology, Medical University of Lódz; Poland.
Department of Endocrinology, Polish Mother's Memorial Hospital – Research Institute, ódz, Poland.

Key words:
goitre; iodine deficiency; classification; diagnostics; treatment

June 7, 2002
Accepted: June 13, 2002

ABSTRACT

In the present review paper, the following problems have been brought up: 1) types of nontoxic goitre and applied classification, 2) physiological periods or states predisposing to non-toxic goitre development, 3) evaluation of excessive stimulation of the thyroid gland, 4) the treatment of iodine deficiency consequences (non-toxic diffuse vs. non-toxic nodular goitre), 5) autoimmunologically-induced non-toxic goitre, and 6) positive effects of iodine prophylaxis with respect to goitre prevalence. The management of non-toxic nodular goitre, as well as of thyroid nodules is a separate and very complex issue, and – at the same time - the subject of our next review paper, published in the same issue of NEL.

Types of non-toxic goitre and
applied classification

The most frequent effect of iodine deficiency is non-toxic goitre, i.e., goitre unaccompanied by thyroid function disorders. Depending on either the absence or the presence of nodules, diagnosed during palpation, non-toxic goitre can be divided into diffuse and nodular, respectively.
The classification of goitre, used in the 80s of the 20th century, with regards to its size determined by palpation [1], is the following:

Grade 0 – no goitre presence is found (the thyroid impalpable and invisible);
Grade 1a – the thyroid gland, however palpable, remains invisible, even in full extension of the neck (the thyroid not enlarged);
Grade 1b – goitre – palpable in normal position and visible in the upright position (full extension) of the neck; nodular goitres are also classified into this size range, even if they do not meet the criteria of enlarged thyroid gland;
Grade 2 – goitre – visible in normal position of the neck; no palpation required to diagnose thyroid enlargement;
Grade 3 – very large goitre, clearly visible from distance.
The actually standing and simplified classification of goitre, as proposed by the WHO [2], refers to the following criteria:

Grade 0 – no goitre presence is found (the thyroid impalpable and invisible);
Grade 1 – neck thickening is present in result of enlarged thyroid, palpable, however, not visible in normal position of the neck; the thickened mass moves upwards during swallowing. Grade 1 includes also nodular goitre if thyroid enlargement remains invisible.
Grade 2 – neck swelling, visible when the neck is in normal position, corresponding to enlarged thyroid – found in palpation.
It should be emphasized that sonographic evaluation of the thyroid size is more accurate in comparison with palpation, being especially recommended in children with small goitre.
The diagnosis of nodular goitre results from palpable examination, i.e., finding of uneven, nodular thyroid surface. The palpable uneven areas correspond to, so-called, hyperplastic nodules, usually present in enlarged thyroid gland. The hyperplastic nodules in nodular goitre are characterized, among others, by the lack of complete connective tissue encapsulation, no distinctive morphological signs of pressure, exerted by the nodules on the adjacent parenchyma of the thyroid gland, what differentiates hyperplastic nodules from neoplastic ones. Thus, nodular goitre is a benign, non-neoplastic lesion and – even if it has been assigned to Class VII in Hedinger et al.'s classification of thyroid tumours (1988) [3] – then, it has been defined in its class as "tumour-like lesion", what corresponds to its actual character. The palpably diagnosed nodular character of thyroid enlargement places the goitre – regardless of its actual size – in, at least, grade 1b in the classification from 1986 [1].
The presence of foci with varied echogenicity, observed in sonographic imaging, which, however, are not palpable, is not the basis for the diagnosis of nodular goitre; it is impossible to reveal occurrence of such foci only by palpation. The management of the, so called, thyroid incidentalomas, will be discussed in detail in our next review paper, published in the same issue of NEL.
Nodular goitre may be either the subject of treatment with L-thyroxine or of surgical intervention [4].

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