Goiter: Cosmetically unpleasant but treatable

by Dr. Melanie Amarasooriya

It grows slowly, into a lump in the front of the neck. It seems to move up and down when you swallow anything. And we call it goiter. Whenever we hear the term 'goiter' or enlarged thyroid gland, iodine deficiency is the cause that runs through our minds.

"Although it is the commonest preventable cause of goiter, it is not the only one", says Dr. Nalitha Wijesundera, a Consultant Surgeon, at Karapitiya Teaching Hospital.

Goiter means simply the enlargement of the thyroid gland. The thyroid is a butterfly shaped structure located in the front of the neck, just below the adam's apple, covered with the thin muscles of the neck.

It produces hormones, mainly thyroxin, a vital chemical to maintain the normal functions of the body. The normal gland is small and not visible to the exterior.

However the gland can get enlarged due to variety of reasons and this enlargement is called "goiter."

The process could be normal, when the thyroid enlarges due to normal processes in the body like pregnancy and puberty. During these periods the gland has to work more, so that the cells multiply and the gland becomes larger in size, retaining the normal shape. However, this resolves when the period of increased demand is over.

Sometimes, goiter occurs because of lack of production of thyroid hormone.

It is fairly common in our country. In this instance, when the output from the thyroid gland is low, due to any particular reason, the pituitary gland in the brain tries to send more and more chemical signals to stimulate the thyroid to increase its hormone production. The result is, the gland getting enlarged gradually in response to this stimulation, but the production of the hormone remains low.

The causes for lack of hormone production by the gland are numerous. If the hormone production is low due to lack of iodine in food, increased iodine intake would reverse this procedure and shrink the gland in the initial stage.

But if there is an intrinsic problem in the gland, making it difficult to produce the necessary amount of thyroxin, iodine would not solve the problem. So the next step is to resort to thyroxin tablets, i.e. to take the thyroxin hormone as a tablet.

This type of thyroid enlargement, occurring due to hormone deficiency is called "hypothyroid goiter" meaning the level of thyroxin in the body is less than the normal.

This could occur from birth, but not very common.

Commoner form of hypothyroid goiters occurs in the middle age, in women, which is not diagnosed until late. This is because the symptoms of these conditions can sometimes be confused with the normal complaints with aging.

To add to the problem their thyroid glands may not be very large, not disfiguring to the extent to seek medical advice. The only symptoms they have are the features of hypothyroidism or lack of thyroxin hormone.

Hypothyroidism

Lethargy weight gain without a significant change in appetite

Constipation

Dry skin

Thin hair

Mental slowness

Hoarse voice

Cold intolerance

Low pulse rate

When the goiter is long standing, it undergoes certain permanent changes so that after a particular point the goiter does not shrink with treatment. In fact it feels nodular or having numerous small lumps in the gland like.

You may also feel one small lump when there are other smaller ones which can not be felt.

At this point if the goiter is large, causing cosmetic problems, difficulty in breathing due to pressure on the respiratory passage or difficulty in swallowing, it needs surgical intervention.

The option is to surgically remove the thyroid gland.

The other entity with thyroid gland is hyperthyroidism or excessive production of thyroid hormones. This is mainly due to abnormal proteins unduly stimulating the gland, to produce excessive hormones. This gives rise to "thyrotoxicosis" with the following features.

Hyperthyroidism

Irritability, Excessive sweating, Diarrhoea, Loss of weight, Increased appetite, Tremor, Warm, Sweaty fingertips, Increased pulse rate.

The usual picture in hyperthyroidism settles in about two years. The objective of the treatment is to reduce symptoms until the gland spontaneously becomes normal.

Therefore, anti thyroid medication are prescribed for about one and half years. However, in certain instances radio active substances can be used to shrink the gland and lessen the production of hormone. Also, once the patient is stable on medication, surgical removal of the gland could also be performed safely so that further such episodes are prevented.

In addition to alterations in the hormonal levels causing a disease process, there are other causes which lead to enlargement of the gland, namely malignancy, or cancers in the thyroid gland.

Although cancers are not as common as harmless enlargement of the gland, thyroid cancer is not a rare one. In fact the commoner varieties of thyroid cancer are seen among young people.

It usually starts as a single nodule in the front of the neck. This nodule may be hard, but painless. There may be accompanying nodules on either side of the neck due to enlargement of lymph nodes.

Thus, whenever there is a lump which developed recently in the front of the neck, it is always advisable to seek medical advice. Recent change in the voice, occurring with a lump also suggests that you need to see a doctor without delay.

However, most of the patients with thyroid cancers do not show symptoms of altered hormone levels.

Their hormone levels are usually normal.

A doctor, after examining the neck can tell you whether the lump arises from the thyroid gland and whether further investigations are necessary. Depending on the findings of examination, you may need to asses the function of the thyroid gland, by blood tests which measure the hormone levels, an ultrasound scan of the neck and fine needle aspiration cytology or FNAC.

In FNAC a small needle is used to obtain few cells from the lump to be examined under the microscope. If these investigations point towards malignancy, you will need surgery to remove whole or part of the gland.

Yet the conclusion of cancer is done only after examining the surgically removed gland.

So even if you undergo removal of part of thyroid gland for a suspected cancer, the final report could come as a 'harmless lump'. Thus thyroid surgery is never synonymous with cancer.

Also if diagnosed early and prompt treatment is given the outcome with thyroid cancers is good. Majority of The young patients who undergo surgical removal of the thyroid gland for common varieties of thyroid cancer can live more or less a normal life.

If the gland is completely removed due to any cause the patient has to be on lifelong thyroxin hormone therapy.

It does not cause any side effects as the pill only contains a hormone which is normally found in the body. Also, patients should not stop the treatment, because thyroxin is a vital hormone to maintain the functions of the body.

(Information provided by Dr. Nalitha Wijesundera , Consultant Surgeon, Karapitiya Teaching Hospital)

Boy babies 'worse for depression'

Giving birth to a boy can increase the likelihood of severe postnatal depression, a study suggests.

French researchers examined 181 mothers, and found 9% had severe depression - three-quarters of these had delivered a male child.

The Journal of Clinical Nursing study suggested earlier poor relationships with men could be a factor for some.

However, a specialist in the UK said the finding, although interesting, could be a "statistical quirk".

* The overwhelming finding of the study was the fact that gender appears to play a significant role in reduced quality of life as well as an increased chance of severe postnatal depression Professor Claude de Tychey University of Nancy Postnatal depression is common among new mothers - the latest study at the University of Nancy found a third of those taking part were affected to some degree.

The women involved were questioned on several different areas of their health, including physical fitness, pain and mental and emotional health.

The researchers, led by Professor Claude de Tychey, found that seven out of ten women who had given birth to a boy reported a lower quality of life compared with the average of women who had given birth to a girl, regardless of whether they had postnatal depression.

Although mothers of girl babies were more likely to have mild postnatal depression, among the 17 women diagnosed with severe postnatal depression, 13 had had male babies.

The researchers did not have any evidence of a reason behind this difference, and called for further research to discover it.

However, although they suggested there might be subtle psychological differences in the attitudes of new mothers towards boy and girl babies which might affect their emotional state - particularly if they were already prone to depression.

They suggested a negative attitude to a son might be a legacy of unsatisfactory relationships with important male figures in their life, such as their father, or partner.

Professor de Tychey said: "The overwhelming finding of the study was the fact that gender appears to play a significant role in reduced quality of life as well as an increased chance of severe postnatal depression.

"Women had the same scores regardless of whether the recent birth was their first or second baby."

However, Dr. Cosmo Hallstrom, a member of the Royal College of Psychiatrists, said the numbers of women with severe depression were too low to draw firm conclusions.

He said severe depression results were compromised by the finding that a majority of the mothers with mild depression were more likely to have given birth to girls.

He said: "It's an interesting talking point, but I'm not entirely convinced by this, and would like to see it replicated in larger trials.

"It's probably a statistical quirk."

BBC NEWS

Psychological problems and bowel disorders

by Dr. R. A. R. Perera, Consultant Psychologist

It is generally accepted that no organic cause can be found for many abdominal pain patients attending medical clinics, even after through laboratory and clinical investigations.

These patients are often labelled as suffering from irritable bowel syndrome. The diagnosis of irritable bowel syndrome is based on the exclusion of organic disease in a patient complaining of abdominal pain and a disordered or irregular bowel habit.

Patients are often subjected to numerous repetitive investigations, even including surgery in some cases. The results of these time-consuming and expensive tests are invariably normal.

Sooner or later the patient's symptoms are ascribed to psychological causes and labelled as functional. There is a widespread belief that psychological factors are paramount in the causation of bowel disorders, although this view has largely arisen on the basis of failure to find organic abnormalities.

Excessive and uncoordinated segmental contractions of the large bowel have been reported in patients with irritable bowel disorder. An abnormal psychological mechanism can cause this disordered function of the bowel.

The tendency to this disorder may be congenital or acquired. Sometimes other members of the family might have similar abdominal pains, which cannot be explained medically.

In Sri Lanka, despite the widespread occurrence of irritable bowel disorder, and the large number of patients in whom the diagnosis is made, few formal studies of the psychological aspect of this condition have been carried out.

There is high incidence of depression, anxiety and marital difficulties in patients complaining of irritable bowel disorders. The obsessional personality, with traits such as orderliness, rigidly, conscientiousness and preoccupation with planing and detail, has been emphasized in these patients. Such people may have a limited awareness of their emotional problems, and a limited capacity for emotional expression.

There is no doubt that emotional states can profoundly affect bowel function. Irritable bowel disorder is a chronic condition characterized by relapses and remissions. There is an association between relapses of this disease and critical life events.

Depression: Changes in appetite and weight are common in depression. Anorexia and retardation of activities, which is associated in depression, can cause constipation. Diarrhoea may occur in agitated patients. Abdominal pain may also be a feature of depression.

Anxiety: The biological accompaniments of anxiety often include diarrhoea. Muscle tension associated with anxiety may produce abdominal pain. Morbid preoccupation with bodily function, and especially bowel function, may be a feature of anxiety states.

Management: It is essential to establish the diagnosis and to carry out all the investigations necessary for the exclusion of organic disease at the outset. After that, the approach to the patient should be holistic, with the emphasis shifting from the somatic to the psychological.

The treatment therefore does not consist of prescribing either an antidepressant or a high fibbre diet, but should be adjusted to suit the circumstances of each individual.

The relationship between the doctor and the patient is especially important. Patients with irritable bowel disorder often need repeated opportunities to discuss their symptoms with the doctor. They are quite likely to have had numerous previous consultations and investigations elsewhere and to have been told that 'there is nothing wrong'.

This generates feelings of frustration and guilt in the patient and lack of sympathy in the relatives.

The doctor should accept, and be seen to accept, that the symptoms are real and not imagined by the patient. Sympathetic supportive psychotherapy will, in most cases, provide greater insight in to the background of the symptoms and thus enable the patient to cope better.

Irritable bowel disorder is a chronic relapsing condition, which extends over many years, sometimes to the childhood. Whatever the treatment, the condition could last for a long period of time.

Lack of improvement should not lead to discontinuation of treatment. It may be helpful to interview the spouse or other members of the family together with the patient, any underlying psychopathology should be treated.

In Sri Lanka, native treatment offered by the 'vedamahaththaya' is a popular way of treating irritable bowel disorder. Some times it is an effective treatment either due to the medications or due to the 'psychotherapy' which is a part of the 'treatment'.