What are the indications for surgery in multinodular non-toxic (MNTG) goitre?

Indications for Surgery in Multinodular Non-Toxic Goiter

Surgery is the definitive treatment for multinodular non-toxic goiter when patients develop compressive symptoms (dysphagia, dyspnea, tracheal compression), have substernal extension, exhibit suspicious nodules requiring malignancy exclusion, or experience cosmetic concerns that significantly impact quality of life. 1, 2, 3

Primary Surgical Indications

Compressive Symptoms

• Respiratory distress including dyspnea, orthopnea, obstructive sleep apnea, or stridor warrants surgical intervention, as these symptoms indicate significant tracheal compression that threatens airway patency 4, 3
• Dysphagia and neck tightness from esophageal compression are clear indications for surgery, as these symptoms directly impair quality of life and nutritional status 5, 3
• CT imaging without contrast should be obtained when obstructive symptoms are present to evaluate the degree of tracheal compression and substernal extension, as this is superior to ultrasound for surgical planning 1, 4

Substernal/Retrosternal Extension

• Goiters with intrathoracic or substernal extension require surgery, as this anatomic configuration is present in over 75% of symptomatic cases and carries higher surgical complexity 3
• Approximately 4% of these cases require sternotomy for complete resection, making early surgical referral important before further growth complicates the procedure 3

Malignancy Concerns

• Fine-needle aspiration biopsy should be performed on nodules >1 cm with suspicious ultrasound features (hypoechogenicity, microcalcifications, irregular borders, taller-than-wide shape, absence of peripheral halo) to exclude malignancy, as approximately 5-7% of multinodular goiters harbor cancer 6, 1, 3
• Surgery is indicated when FNA results show suspicious or malignant cytology, as this is the only way to definitively exclude cancer and provide appropriate staging 6, 1
• Even when microcarcinomas are found (as occurred in 7% of surgical cases), 56% are multifocal, justifying total thyroidectomy to prevent recurrence 3

Cosmetic Deformity

• Significant cosmetic concerns that impact patient quality of life represent a valid surgical indication, particularly when the goiter causes visible neck deformity 2, 7

Total Thyroidectomy vs. Partial Resection

Total thyroidectomy is strongly preferred over partial thyroidectomy for multinodular non-toxic goiter, as partial surgery carries a 28% recurrence rate with 67% of recurrences requiring completion thyroidectomy 3

• Total thyroidectomy definitively prevents recurrence, avoids the need for reoperation (which carries higher morbidity), and allows complete pathologic examination to exclude multifocal malignancy 3
• Permanent recurrent laryngeal nerve injury occurs in only 3% of cases, and permanent morbidity rates are low when surgery is performed by experienced surgeons 3

When Surgery Is NOT Indicated

Observation Strategy

• Small, asymptomatic multinodular goiters with normal TSH levels and benign FNA results can be managed with yearly clinical observation including TSH measurement and thyroid palpation 2
• Patients with modest but stable goiter size and normal TSH levels may continue observation without intervention 2

Failed Non-Surgical Alternatives

• Levothyroxine suppression therapy is NOT recommended for routine use in multinodular non-toxic goiter, as it has low efficacy, potential cardiovascular and bone side effects, and is specifically contraindicated when TSH is already suppressed 2, 8, 5
• Radioiodine therapy, even when augmented with recombinant human TSH, remains experimental and is not established as standard treatment for non-toxic multinodular goiter, though it may be considered in patients with surgical contraindications 8, 5

Critical Diagnostic Workup Before Surgery

• Ultrasound is the mandatory first-line imaging to characterize nodule morphology and identify which nodules require FNA 1
• Serum TSH measurement is essential to confirm euthyroid status, as suppressed TSH indicates toxic multinodular goiter requiring different management 1, 2
• Avoid radionuclide scanning in euthyroid patients, as most nodules are "cold" and most cold nodules are benign, making this test unhelpful for determining malignancy risk 1

Common Pitfalls to Avoid

• Do not delay surgery in patients with progressive compressive symptoms, as long-standing goiters (>10 years evolution) are more likely to have intrathoracic extension and require sternotomy 3
• Do not attempt levothyroxine suppression in patients with already suppressed TSH, as this causes iatrogenic thyrotoxicosis without benefit 2
• Do not skip FNA on suspicious nodules based solely on the multinodular nature of the goiter, as malignancy risk persists at 5-7% 1, 3
• Do not perform partial thyroidectomy expecting equivalent outcomes to total thyroidectomy, as the 28% recurrence rate makes this approach inferior for definitive management 3