From the Guidelines
Multinodular goiter (MNG) is a condition where the thyroid gland becomes enlarged with multiple nodules, and the most recent and highest quality study recommends that treatment depends on the size, symptoms, and whether the nodules are producing excess thyroid hormones 1. The symptoms of MNG include:
- A visible swelling in the neck
- Difficulty swallowing or breathing
- Hoarseness
- Rarely, hyperthyroidism symptoms like weight loss, anxiety, and heat intolerance Most multinodular goitres are benign and asymptomatic, requiring only monitoring through regular physical examinations and thyroid function tests.
Treatment options for MNG include:
- Watchful waiting for small, asymptomatic goitres
- Levothyroxine to suppress thyroid growth in some cases, typically at doses of 1.6-1.8 mcg/kg daily
- Antithyroid medications like methimazole (10-30 mg daily) or propylthiouracil (100-300 mg daily in divided doses) to normalize hormone levels for hyperthyroid goitres
- Surgical removal (thyroidectomy) for large goitres causing compressive symptoms
- Radioactive iodine therapy (typically a single dose of 10-29.9 mCi) as an alternative for hyperthyroid goitres in patients who are not surgical candidates The treatment approach is individualized based on the patient's age, overall health, and the specific characteristics of their goitre, with the goal of relieving symptoms and preventing complications while maintaining normal thyroid function 1. It is also important to note that fine needle aspiration cytology (FNAC) is an important technique that is used along with US for the diagnosis of thyroid nodules, and should be performed in any thyroid nodule >1 cm and in those <1 cm if there is any clinical or ultrasonographic suspicion of malignancy 1.
From the Research
Symptoms of Multinodular Goiter (MNG)
- The clinical presentation of patients with multinodular goiter is variable and dependent on size, location, and the functional state of the thyroid tissue 2
- The most frequent clinical symptoms are caused by compression and deviation of the trachea and range from dyspnoea to acute asphyxia 2
- Nodular goiters may be asymptomatic, with normal TSH levels (nontoxic), or may be associated with systemic thyrotoxic symptoms (toxic MNG or Plummer's disease) 3
- Symptoms can also include local compression symptoms attributed to the goiter, such as difficulty swallowing or breathing 3
Treatment Options for MNG
- Indications for treatment in patients with MNG include hyperthyroidism, local compression symptoms attributed to the goiter, cosmesis, and concern about malignancy based on FNA results 3
- Treatment options for MNG include:
- Surgery: preferred treatment for large nontoxic multinodular goiters with local compression symptoms 3, 2
- Radioiodine therapy: effective therapy for many patients with toxic MNG, and can also be used for non-toxic MNG 3, 4, 5, 2, 6
- Levothyroxine suppression therapy: can be used to decrease and control MNG size, but its use is controversial and should not be used in patients with suppressed serum TSH levels 3
- Recombinant human thyrotropin (rhTSH)-aided radioiodine therapy: can increase radioiodine uptake and reduce thyroid volume of the multinodular goiter, but its benefits and risks are still being studied 4, 5, 6
Diagnostic Evaluation of MNG
- Diagnostic evaluation of patients with nodular goiters consists of clinical evaluation, biochemical testing, FNA, and imaging studies 3
- The serum TSH level is a sensitive and reliable index of thyroid function 3
- FNA results are pivotal to assess cancer risk in patient management for prominent palpable and suspicious nodules 3
- Imaging studies, such as chest radiography, high-resolution ultrasonography, and computed tomography, can help to delineate the size and extent of a goiter in evaluating compression symptoms 3