Nontoxic Multinodular Goiter

Nontoxic multinodular goitre is an enlarged nodular thyroid with normal thyroid function.

• Iodine deficiency is the main global cause; also genetic, smoking, female sex.
• Prevalence increases with age; retrosternal extension in 10 to 20%.
• Cancer found in 5 to 10% of surgical specimens.

• Neck swelling, asymptomatic or compressive: dysphagia, dyspnoea (especially supine), stridor, hoarseness.
• Pemberton sign (facial plethora on raising arms) with thoracic inlet obstruction.
• Euthyroid; may become toxic over time.

• TSH (with free T4 if abnormal), ultrasound of the neck.
• Fine needle aspiration of nodules with suspicious features or over 1 cm (ultrasound pattern based).
• CT neck/chest for retrosternal extension and tracheal compression; flow volume loop.
• Radioiodine scan if TSH low.

• Observation with periodic ultrasound if asymptomatic and benign.
• Surgery (total or near total thyroidectomy) for compressive symptoms, retrosternal extension, suspicion of cancer, cosmetic concerns.
• Radioiodine for non surgical candidates (recombinant TSH 0.1 mg pre stimulation improves volume reduction by 35 to 50%).
• Levothyroxine suppression is not recommended.
• Iodine repletion in deficient populations.
• Follow TSH and symptoms yearly; postoperative levothyroxine 1.6 micrograms/kg/day.