What are the investigations and treatment options for goiter (enlargement of the thyroid gland)?

From the Guidelines

Investigations for goitre should begin with a thorough clinical assessment, followed by thyroid function tests (TSH, free T4, free T3) to determine thyroid status, as recommended by the most recent evidence 1. The initial assessment should include a thorough medical history and physical examination to identify any symptoms or signs of thyroid dysfunction.

• Thyroid function tests, including TSH, free T4, and free T3, should be performed to determine the underlying cause of the goitre.
• Ultrasound is the first-line imaging modality to evaluate goitre structure, nodularity, and characteristics of any nodules, as stated in the ACR Appropriateness Criteria for thyroid disease 1.
• Fine needle aspiration cytology (FNAC) should be performed for suspicious nodules based on ultrasound findings.
• Additional tests may include thyroid antibodies (anti-TPO, anti-thyroglobulin) to assess for autoimmune thyroid disease, and thyroid scintigraphy to evaluate functional status of nodules.

Treatment depends on the underlying cause of the goitre.

• For hypothyroid goitre, levothyroxine (starting at 25-50mcg daily, titrated based on TSH levels) is prescribed, as recommended by the US Preventive Services Task Force 1.
• Hyperthyroid goitre may require anti-thyroid medications like carbimazole (starting at 20-40mg daily) or propylthiouracil (100-150mg three times daily), with dose adjustments based on thyroid function tests every 4-6 weeks.
• Radioactive iodine therapy or surgery may be considered for persistent hyperthyroidism.
• For euthyroid goitre, observation is appropriate if the goitre is small and asymptomatic.
• Surgical intervention (total or partial thyroidectomy) is indicated for large goitres causing compressive symptoms, cosmetic concerns, or suspicious/malignant nodules, as recommended by the ACR Appropriateness Criteria for thyroid disease 1. The choice of treatment should consider the patient's age, comorbidities, goitre size, symptoms, and preferences, with regular follow-up to monitor treatment response.

From the FDA Drug Label

Methimazole tablets, USP are indicated: In patients with Graves’ disease with hyperthyroidism or toxic multinodular goiter for whom surgery or radioactive iodine therapy is not an appropriate treatment option. Propylthiouracil is indicated: in patients with Graves’ disease with hyperthyroidism or toxic multinodular goiter who are intolerant of methimazole and for whom surgery or radioactive iodine therapy is not an appropriate treatment option.

The treatment options for goiter (enlargement of the thyroid gland) include:

• Medications: methimazole or propylthiouracil to ameliorate symptoms of hyperthyroidism
• Surgery: thyroidectomy (removal of the thyroid gland)
• Radioactive iodine therapy: to decrease symptoms of hyperthyroidism 2 3 3

From the Research

Investigations for Goiter

• The appropriate first test for all patients with goiter is thyroid stimulating hormone (TSH) 4
• If TSH is low, a radionuclide scan is helpful 4
• Thyroid ultrasound has become an extension of physical examination and should be performed in all patients with goiter to determine which nodules should be biopsied 4
• Biochemical tests such as serum TSH measurement, thyroid hormone measurement, and thyroid ultrasonography are used for diagnosis of multinodular goiter (MNG) 5
• Thyroid scintigraphy may be used if there is abnormal TSH measurement 5
• Fine-needle aspiration biopsy and some cross-sectional imaging methods (computed tomography, magnetic resonance imaging, and positron emission imaging) could be used for diagnosis 5

Treatment Options for Goiter

• Treatment options for goiter depend on the cause and the clinical picture 4
• Observation, iodine supplementation, thyroxine suppression, thionamide medication (carbimazole or propylthiouracil), radioactive iodine ablation, and surgery are possible treatment options for goiter 4
• Iodine supplementation at a level recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) can quickly normalize thyroid function tests in patients with endemic goiter 6
• Treatment with levothyroxine is not required in endemic goiter as thyroid function tests generally normalize with the addition of iodine to the diet/total parenteral nutrition regimen 6
• Patients with compression symptoms due to an enlarged thyroid gland are usually candidates for surgery 5
• Medical follow-up, lobectomy, or thyroidectomy are options for treatment of non-toxic multinodular goiter (MNG) 5