What is the initial treatment for nodular goitre?

Initial Treatment for Nodular Goitre

The initial treatment for nodular goitre begins with thyroid ultrasound supplemented by fine needle aspiration cytology (FNAC) to rule out malignancy, followed by serum TSH measurement to assess thyroid function—most patients with benign nodules require no treatment beyond observation. 1, 2

Diagnostic Workup First

Before any treatment decision, proper characterization is essential:

• Perform thyroid ultrasound to detect and characterize the nodular disease 1, 2
• Measure serum TSH before proceeding with further evaluation, as this determines functional status and guides management 2
• Conduct FNAC for nodules >1 cm or smaller nodules with suspicious ultrasound features (microcalcifications, central hypervascularity, taller-than-wide shape) 1, 2
• Use ultrasound-guided FNA rather than palpation-guided, as it is more accurate and effective 2

The FNAC result is pivotal—it determines whether you observe, treat medically, or proceed to surgery 3, 4.

Treatment Algorithm Based on Nodule Characteristics

For Benign, Asymptomatic Nodules (Most Common Scenario)

No treatment is needed after malignancy is ruled out 3. The evidence strongly supports observation over routine intervention:

• Yearly clinical observation with TSH monitoring is sufficient for small, stable nodules 4
• Levothyroxine suppressive therapy should NOT be routinely recommended despite its widespread historical use 3
• While one 5-year randomized trial showed L-T4 prevented new nodule formation and volume increases, it only induced shrinkage in a subgroup of patients and carries risks of exogenous hyperthyroidism 5
• Reserve L-T4 suppression only for small nodules in younger patients if treatment is deemed necessary, but recognize this is controversial 5

For Symptomatic Nontoxic Nodular Goitre

Surgery is the first-choice treatment when patients have compression symptoms (trachea, esophagus), cosmetic concerns, or significant documented growth 3, 4, 6:

• Surgery provides definitive treatment with immediate symptom relief 4, 7
• Radioiodine is an alternative if uptake is adequate, particularly in multinodular goitre 3, 7
• Percutaneous ethanol injection (PEI) can be used for solitary nodules, whether hot or cold 3, 7

For Toxic (Hyperfunctioning) Nodular Goitre

When TSH is suppressed and the patient has thyrotoxic symptoms:

• Surgery or radioiodine are both recommended definitive treatments 4, 7
• Patients with large goitres and large autonomously functioning nodules become euthyroid more quickly with surgery 4
• Thionamides control hyperthyroidism temporarily in preparation for definitive therapy but are rarely used long-term 7
• For toxic solitary adenomas, radioiodine is the therapy of choice 3

For Follicular Neoplasia on FNAC

Surgery should be considered when FNAC shows follicular neoplasia with normal TSH and "cold" appearance on thyroid scan 1, as cytology cannot distinguish follicular adenoma from carcinoma 2.

Critical Pitfalls to Avoid

• Do not use L-T4 suppression in patients with already suppressed TSH levels—this risks inducing toxic symptoms 4
• Do not let a reassuring FNA override worrisome clinical findings, as false-negative results occur 2
• Repeat inadequate or nondiagnostic FNA rather than proceeding based on insufficient cytology 1, 2
• Measure serum calcitonin as part of the diagnostic evaluation to detect medullary thyroid cancer, which has higher sensitivity than FNA alone 1, 2

Special Considerations

For multinodular goitre, malignancy risk is equivalent to solitary nodules, so the same diagnostic rigor with FNAC of dominant or suspicious nodules is warranted 3, 4. Emerging therapies like thermal ablation show promise for selected cases but currently lack long-term high-level evidence 1.