ABSTRACT
Goiter prevalence of 5–10% in a given region or country makes that area endemic for goiter. Iodine deficiency is the main etiological factor for goiter world over. Iodine deficiency remains a large global health problem. It is estimated that around 2 billion individuals worldwide do not take adequate iodine in their diet. The universal salt iodization program has eliminated endemic goiter in certain parts of the world, yet there are certain areas in Asia and sub-Saharan Africa where iodine deficiency remains a problem. The prevalence of very large goiter seen previously is less after iodization. Overall, the benefits of iodization outweigh the risks of iodization.
The assessment of goiter in an endemic setting must follow the same process like any other goiter. Clinical examination plays an important role in the assessment. Grading of goiters according to the modified WHO classification clinically will make the assessment uniform.
The standard assessment of an endemic goiter must include an ultrasound scan for confirmation of morphology, hormone assay to determine the functional status and fine needle cytology (FNC) to assess the pathology of the lesion. Other investigations must be requested for specific reasons, e.g., thyroid antibodies to diagnose autoimmune thyroiditis or a CT scan to determine the retrosternal extension of a goiter. The cost-effectiveness of the assessment is critical in a developing economy. Based on morphology and function, endemic goiters can be categorized into several groups. The commonest endemic goiter is the euthyroid multinodular/colloid goiter.
In terms of definitive management, some endemic goiter may not need any intervention and can be observed and followed up. Others will need antithyroid drugs to control excess function or replacement thyroxine therapy for hypofunction. There is no role for blind/empirical thyroxine therapy in the management of endemic goiters. If surgery is to be undertaken, the patient should be euthyroid. A consensus is emerging that total thyroidectomy is the best option as it prevents recurrence and deals with incidental cancers that occur in over 10% of patients. The axiom of management of endemic goiters should be “Primum non nocere” – “First do no harm”.
