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What Causes Large Lump On Right Side Of Thyroid With Normal TSH Levels?
Question: 3 years ago I started out with Hyperthyroidism with Goiter and Multinodules and the Dominant one being in the right Lobe with a smaller dominant on the left. I have noticed that my T4 has slowly been declining to now being 0.79. According to the Dr. I currently go to who is new to me because of a move, my TSH is fine, T4 low, Lymphs and Potassium high and, there are no dominant Nodules. Is it possible that everything that was happening to me until August of last year is no longer there. I still have a large lump on the right side of the Thyroid and it is very protruding. What happens to the Nodules if they are no longer dominant which I am assuming means larger than the others. What happens that makes them no longer dominant, do the others increase in size or is it possible they shrunk in size?? I am on what I call a Roller Coaster ride both emotionally and with so many mixed symptoms. Some appear to be associated with Hyper and the others with Hypo. Please explain. Thanks for your time.
XXXXXXX XXXXXXX
XXXXXXX XXXXXXX
Brief Answer:
Thyroid
Detailed Answer:
I understand your concerns. Thyroid conditions can be complex to comprehend.
It appears your diagnosis was Toxic Multinodular goiter. The most accurate way to confirm this is to have undergone a Radioactive Iodine 123 uptake and scan test, best done at diagnosis before treatment is begun.
I say 'was' because according to you, you were told to have hyperthyroidism although now your TSH is fine.
This implies that 3 years ago your TSH would have been low with or without elevated T3/T4 levels. If the TSH was in normal range it is extremely unlikely you had hyperthyroidism back then. However, if the TSH was low but the T3/T4 were not high, then a rare condition called Secondary hypothyroidism was required to be ruled out then too.
Coming to the present time, where it seems your TSH is fine and T4 is declining, this is what I would plan if I saw a patient like you in my practice:
1 Order a fresh Free T4 blood test, preferably at a laboratory where they use the Direct Dialysis method to run the test. I would go by the reference range on the report to interpret the Free T4 values.
2 I would order further blood tests on the same sample for:
Total T3
CMP
A1c
Prolactin
TSH
These tests will give us a fair idea where you stand with regards to the thyroid status now as well as help explore potential causes of elevated lymphs and potassium.
I see you are on no medications whatsoever. Kindly confirm.
Regarding nodules, dominant or otherwise, in the thyroid, there is a small risk of cancer (5%) in general which varies depending on multiple factors such as:
1 Chance of cancer is extremely low if the nodule is overactive. To determine which one is overactive, first the TSH will need to be suppressed ie below normal and only then can one proceed with the uptake and scan test which will indicate which nodule(s) is/are overactive, if any.
2 Chance of cancer is higher in those who have:
had thyroid cancer in the past
have an immediate family member with thyroid cancer
had exposure to upper body radiation (for head/neck area cancers or acne/adenoids)
certain suspicious characteristics on Ultrasound examination
Pressure symptoms in the neck such as pain or difficulty in breathing/speaking/swallowing or change in voice/hoarseness
A fine needle biopsy can be planned after the above considerations are addressed in thorough detail.
I suggest you see an endocrinologist in person
Thyroid
Detailed Answer:
I understand your concerns. Thyroid conditions can be complex to comprehend.
It appears your diagnosis was Toxic Multinodular goiter. The most accurate way to confirm this is to have undergone a Radioactive Iodine 123 uptake and scan test, best done at diagnosis before treatment is begun.
I say 'was' because according to you, you were told to have hyperthyroidism although now your TSH is fine.
This implies that 3 years ago your TSH would have been low with or without elevated T3/T4 levels. If the TSH was in normal range it is extremely unlikely you had hyperthyroidism back then. However, if the TSH was low but the T3/T4 were not high, then a rare condition called Secondary hypothyroidism was required to be ruled out then too.
Coming to the present time, where it seems your TSH is fine and T4 is declining, this is what I would plan if I saw a patient like you in my practice:
1 Order a fresh Free T4 blood test, preferably at a laboratory where they use the Direct Dialysis method to run the test. I would go by the reference range on the report to interpret the Free T4 values.
2 I would order further blood tests on the same sample for:
Total T3
CMP
A1c
Prolactin
TSH
These tests will give us a fair idea where you stand with regards to the thyroid status now as well as help explore potential causes of elevated lymphs and potassium.
I see you are on no medications whatsoever. Kindly confirm.
Regarding nodules, dominant or otherwise, in the thyroid, there is a small risk of cancer (5%) in general which varies depending on multiple factors such as:
1 Chance of cancer is extremely low if the nodule is overactive. To determine which one is overactive, first the TSH will need to be suppressed ie below normal and only then can one proceed with the uptake and scan test which will indicate which nodule(s) is/are overactive, if any.
2 Chance of cancer is higher in those who have:
had thyroid cancer in the past
have an immediate family member with thyroid cancer
had exposure to upper body radiation (for head/neck area cancers or acne/adenoids)
certain suspicious characteristics on Ultrasound examination
Pressure symptoms in the neck such as pain or difficulty in breathing/speaking/swallowing or change in voice/hoarseness
A fine needle biopsy can be planned after the above considerations are addressed in thorough detail.
I suggest you see an endocrinologist in person
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your answer, let me elaborate better for you.
On 07-25-11 I had a Nuclear Medicine Thyroid Scan.
The Results:
IMPRESSION: THE GENERAL APPEARANCE OF THE GLANDS SUGGEST A MULTINODULAR GOITER, HOWEVER, THE VERY INTENSE ACTIVITY IN THE RIGHT MID POLE SUGGESTS ADENOMA WITH DEVELOPING SUPPRESSION OF ACTIVITY IN THE REMAINDER OF THE GLAND, PATCHY AS NOTED.
IMPRESSION: HYPERTHYROID STATE.
Thyroid issues were discovered in 2011. The last three tests done, two at one place and one at another Lab are as follows:
April 17 2013
FT3 3.6 Normal Range 2.3-4.2
FT4 1.14 Normal Range 0.62-1.57
TSH 0.585 Normal Range 0.350-5.500
July 16 2013
FT4 0.98 Normal Range 0.62-1.57
TSH 0.307 Normal Range 0.350-5.500
November 03 2014 (Different Lab)
TSH 0.831 Normal Range 0.450-4.500
FT4 0.76 Normal Range 0.82-1.77
Lmyphs 3.5 Normal Range 0.7-3.1
T3 results on the November 3rd results. It is:
126 with a Normal Range of 71-180. So that appears normal. I have the Thyroglobulin Antibody on here as well. It is: <1.0 IU/mL Normal Range 0.00-0.9.
I have a larger than 2.3cm dominant nodule on the right side and numerous smaller nodules with the next largest on the left side.
I had a FNAB done in 2011 with no cancer evident.
The Dr. of the last results is new.
Added symptoms. Heart racing periodically, heart beats over 100 on normal sitting quietly. Extreme Sweating. 20 degrees outside I am hot. Any exercise, I am profusely sweating. Night time I am cold and turn on bed heat in winter. Mood swings, too the point I sometimes wonder why I am even on this earth. Luckily I know who I am and can shake these thoughts off with effort and telling myself to stop these stupid thoughts. Weigh gain in huge amounts. 135lb normal weight to 186lbs in three years. Now reverse, loss from 186lbs to 158lbs in 4 months. Low energy for several days and sudden high energy again and clear thoughts. On low energy days I go about the day totally confused at what I am doing. Start a project, stop, go to something else and then suddenly forget what I was doing at all. Have to stop and regroup, try to clear my head and start over. Loss of memory and time is becoming permanent. Mood changes to anger with no real reason.. On good energy spans I focus and accomplish much with good and clear short term memory. Happy with no mood change.
I am 62 and have a very busy Lifestyle in the Companion Animal Field, Groomer, Trainer, Used to show, my day starts at 5am and ends at 10pm of which I used to be active throughout the day. On good days that is still the case. I do all the repair work on the fencing, shovel gravel and am still extremely strong for my age.
My current Dr. answers to latest blood levels is do another FNAB and look at surgery to stop the pressure on my windpipe when I sleep. First off I DON'T want surgery, secondly the pressure is there but not enough to warrant surgery. I want to control the Roller Coaster ride. I want to know how to approach the Dr. about taking care of these symptoms because he does not appear to hear me when I speak. He looks at the blood results and tell me that it is not the Thyroid causing these. I have no other medical issues except for DJD and Spondyolothesis of which I both control because I am so active. A little arthritis is setting in due to age. I feel like I am headed for Dementia if I don't get this under control and find a Dr. that is willing to treat symptoms. I never know when I wake up what type of day and energy this day will bring to me or if the Roller Coaster ride is about to change again. Shaking inside is a new symptom for me the last month during the high of the Roller Coaster.
The Scan I had in August 2013. The results read: Impression: A multinodular thyroid appearance is again demonstrated with the larger and more complex nodules on the right side. The dominant right nodule is amenable to fine needle aspiration should be considered given it's size. The adjacent nodule with central echogenic foci should also be consideration for sampling given the appearance of possible calcifications versus colloid foci.
Dr at the time did not feel a FNAB was needed due to recent one done.
My current Dr prescribed Lopressor but I was afraid to take it because of my low blood pressure. (70/120) Also I am on the down side again of this and do not feel the racing heart as heavily as I did.
The latest experience I had was a pressure headache with veins in my eyes bleeding. I do have three bulging disks in my neck and could be a contributing factor to those headaches though.
I did write you a more detailed review but I don't know where it went because it did not show up here so I am doing it again.
One more thing, the tests you speak of above, can I have these done myself. If so how do I go about that and can you elaborate on what I need to ask for??
What I did not tell you in the above is that my mother had Thyroid Cancer in her 70's and had surgery for it. I was not around her during that time so do not know the circumstances behind any of it or the type of surgery. My niece did state she had the surgery and Radiation treatments afterwards.
Regards, XXXXXXX XXXXXXX
On 07-25-11 I had a Nuclear Medicine Thyroid Scan.
The Results:
IMPRESSION: THE GENERAL APPEARANCE OF THE GLANDS SUGGEST A MULTINODULAR GOITER, HOWEVER, THE VERY INTENSE ACTIVITY IN THE RIGHT MID POLE SUGGESTS ADENOMA WITH DEVELOPING SUPPRESSION OF ACTIVITY IN THE REMAINDER OF THE GLAND, PATCHY AS NOTED.
IMPRESSION: HYPERTHYROID STATE.
Thyroid issues were discovered in 2011. The last three tests done, two at one place and one at another Lab are as follows:
April 17 2013
FT3 3.6 Normal Range 2.3-4.2
FT4 1.14 Normal Range 0.62-1.57
TSH 0.585 Normal Range 0.350-5.500
July 16 2013
FT4 0.98 Normal Range 0.62-1.57
TSH 0.307 Normal Range 0.350-5.500
November 03 2014 (Different Lab)
TSH 0.831 Normal Range 0.450-4.500
FT4 0.76 Normal Range 0.82-1.77
Lmyphs 3.5 Normal Range 0.7-3.1
T3 results on the November 3rd results. It is:
126 with a Normal Range of 71-180. So that appears normal. I have the Thyroglobulin Antibody on here as well. It is: <1.0 IU/mL Normal Range 0.00-0.9.
I have a larger than 2.3cm dominant nodule on the right side and numerous smaller nodules with the next largest on the left side.
I had a FNAB done in 2011 with no cancer evident.
The Dr. of the last results is new.
Added symptoms. Heart racing periodically, heart beats over 100 on normal sitting quietly. Extreme Sweating. 20 degrees outside I am hot. Any exercise, I am profusely sweating. Night time I am cold and turn on bed heat in winter. Mood swings, too the point I sometimes wonder why I am even on this earth. Luckily I know who I am and can shake these thoughts off with effort and telling myself to stop these stupid thoughts. Weigh gain in huge amounts. 135lb normal weight to 186lbs in three years. Now reverse, loss from 186lbs to 158lbs in 4 months. Low energy for several days and sudden high energy again and clear thoughts. On low energy days I go about the day totally confused at what I am doing. Start a project, stop, go to something else and then suddenly forget what I was doing at all. Have to stop and regroup, try to clear my head and start over. Loss of memory and time is becoming permanent. Mood changes to anger with no real reason.. On good energy spans I focus and accomplish much with good and clear short term memory. Happy with no mood change.
I am 62 and have a very busy Lifestyle in the Companion Animal Field, Groomer, Trainer, Used to show, my day starts at 5am and ends at 10pm of which I used to be active throughout the day. On good days that is still the case. I do all the repair work on the fencing, shovel gravel and am still extremely strong for my age.
My current Dr. answers to latest blood levels is do another FNAB and look at surgery to stop the pressure on my windpipe when I sleep. First off I DON'T want surgery, secondly the pressure is there but not enough to warrant surgery. I want to control the Roller Coaster ride. I want to know how to approach the Dr. about taking care of these symptoms because he does not appear to hear me when I speak. He looks at the blood results and tell me that it is not the Thyroid causing these. I have no other medical issues except for DJD and Spondyolothesis of which I both control because I am so active. A little arthritis is setting in due to age. I feel like I am headed for Dementia if I don't get this under control and find a Dr. that is willing to treat symptoms. I never know when I wake up what type of day and energy this day will bring to me or if the Roller Coaster ride is about to change again. Shaking inside is a new symptom for me the last month during the high of the Roller Coaster.
The Scan I had in August 2013. The results read: Impression: A multinodular thyroid appearance is again demonstrated with the larger and more complex nodules on the right side. The dominant right nodule is amenable to fine needle aspiration should be considered given it's size. The adjacent nodule with central echogenic foci should also be consideration for sampling given the appearance of possible calcifications versus colloid foci.
Dr at the time did not feel a FNAB was needed due to recent one done.
My current Dr prescribed Lopressor but I was afraid to take it because of my low blood pressure. (70/120) Also I am on the down side again of this and do not feel the racing heart as heavily as I did.
The latest experience I had was a pressure headache with veins in my eyes bleeding. I do have three bulging disks in my neck and could be a contributing factor to those headaches though.
I did write you a more detailed review but I don't know where it went because it did not show up here so I am doing it again.
One more thing, the tests you speak of above, can I have these done myself. If so how do I go about that and can you elaborate on what I need to ask for??
What I did not tell you in the above is that my mother had Thyroid Cancer in her 70's and had surgery for it. I was not around her during that time so do not know the circumstances behind any of it or the type of surgery. My niece did state she had the surgery and Radiation treatments afterwards.
Regards, XXXXXXX XXXXXXX
Brief Answer:
Follow up
Detailed Answer:
I have reviewed your notes extensively. It would be prudent to do at least couple tasks. One, request your doctor to consider the possibility of Secondary hypothyroidism, as I described in my first response. Blood tests for FSH, LH and Prolactin will assist partially in determining the likelihood of this condition. To know with reasonable certainty will entail a thorough in-person examination preferably by an endocrinologist who may even consider ordering an MRI scan of the pituitary. Secondly, an FNAB of the nodules seems worthwhile again. Discuss this with the endocrinologist one on one. Thirdly, the tests is have suggested will need a doctors order. Just mention them as is and it is self explanatory to healthcare providers/ labs. For example CMP includes sodium, potassium, chloride, glucose, calcium, bicarbonate, creatinine, ALT, AST, bilirubin, albumin.
Follow up
Detailed Answer:
I have reviewed your notes extensively. It would be prudent to do at least couple tasks. One, request your doctor to consider the possibility of Secondary hypothyroidism, as I described in my first response. Blood tests for FSH, LH and Prolactin will assist partially in determining the likelihood of this condition. To know with reasonable certainty will entail a thorough in-person examination preferably by an endocrinologist who may even consider ordering an MRI scan of the pituitary. Secondly, an FNAB of the nodules seems worthwhile again. Discuss this with the endocrinologist one on one. Thirdly, the tests is have suggested will need a doctors order. Just mention them as is and it is self explanatory to healthcare providers/ labs. For example CMP includes sodium, potassium, chloride, glucose, calcium, bicarbonate, creatinine, ALT, AST, bilirubin, albumin.
Note: For more information on hormonal imbalance symptoms or unmanaged diabetes with other comorbid conditions, get back to us & Consult with an Endocrinologist. Click here to book an appointment.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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