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Common in regions of the world with low-iodine diets High rate of congenital hypothyroidism and cretinism Goiters may become multinodular and grow to great size Most adults with endemic goiter are found to be euthyroid; however, some are hypothyroid or hyperthyroid Impaired cognition and hearing may be subtle or severe in congenital hypothyroidism

Approximately 5% of the world s population have goiters Of these, about 75% are in persons dwelling in areas of iodine deficiency Such areas are found in 115 countries, mostly in developing areas but also in Europe In iodinedeficient patients, smoking or pregnancy can induce goiter growth In Pescopagano, Italy, 60% of adults have goiters Hyperthyroidism (present or past) occurred in 29%; hypothyroidism was overt in 02% and subclinical in 38% The incidence of thyroid cancer was less than 01% Up to 05% of iodinedeficient populations have full-blown cretinism, with less severe manifestations of congenital hypothyroidism being even more common (eg, isolated deafness, short stature, or impaired mentation) Intelligence quotients in iodine-deficient adults are an average of 13 points lower than expected Although iodine deficiency is the most common cause of endemic goiter, certain foods (eg, sorghum, millet, maize, cassava), mineral deficiencies (selenium, iron), and water pollutants can themselves cause goiter or aggravate a goiter proclivity caused by iodine deficiency Pregnancy is associated with an increase in size of thyroid nodules and the emergence of new nodules Some individuals are particularly susceptible to goiter owing to congenital partial defects in thyroid enzyme activity

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Endemic goiters may become multinodular and very large Growth often occurs during pregnancy and may cause compressive symptoms

individuals with autonomous multinodular goiters; therefore, levothyroxine suppression should not be started in patients with suppressed TSH levels Adults with large multinodular goiter may require thyroidectomy for cosmesis, compressive symptoms, or thyrotoxicosis Following partial thyroidectomy in iodinedeficient geographic areas, there is a high goiter recurrence rate, so total thyroidectomy is preferred when surgery is indicated Certain patients may be treated with 131I for large compressive goiters; rarely, Graves' disease may develop 3 10 months after treatment

Bellantone R et al Predictive factors for recurrence after thyroid lobectomy for unilateral non-toxic goiter in an endemic area: results of a multivariate analysis Surgery 2004 Dec;136(6): 1247 51 [PMID: 15657583] Valentino R et al Screening a coastal population in Southern Italy: iodine deficiency and prevalence of goitre, nutritional aspects and cardiovascular risk factors Nutr Metab Cardiovasc Dis 2004 Feb;14(1):15 9 [PMID: 15053159]

Substernal goiters are usually asymptomatic but can cause tracheal compression, respiratory distress and failure, dysphagia, superior vena cava syndrome, gastrointestinal bleeding from esophageal varices, palsies of the phrenic or recurrent laryngeal nerves, or Horner s syndrome Cerebral ischemia and stroke can result from arterial compression or thyrocervical steal syndrome Substernal goiters can rarely cause pleural or pericardial effusions The incidence of significant malignancy is less than 1% Some patients with endemic goiter may become hypothyroid Others may become thyrotoxic as the goiter grows and becomes more autonomous, especially if iodine is added to the diet

The serum T4 is usually normal Serum TSH is generally normal TSH falls in the presence of hyperthyroidism if a multinodular goiter has become autonomous in the presence of sufficient amounts of iodine for thyroid hormone synthesis TSH rises with hypothyroidism Thyroid RAI uptake is usually elevated, but it may be normal if iodine intake has improved Serum levels of antithyroid antibodies are usually either undetectable or in low titers Serum thyroglobulin is often elevated

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Parathyroid hormone (PTH) increases osteoclastic activity in bone, increases the renal tubular reabsorption of calcium, and stimulates the synthesis of 1,25-dihydroxycholecalciferol by the kidney Meanwhile, PTH inhibits the absorption of phosphate and bicarbonate by the renal tubule All of these actions cause a net increase in serum calcium

Endemic goiter must be distinguished from all other forms of nodular goiter that may coexist in an endemic region (see above)

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