What are the initial treatment recommendations for a patient with a simple goiter, considering the underlying cause, size, and symptoms?

Management of Goiter

Initial Diagnostic Approach

Ultrasound is the first-line imaging modality for all patients with suspected goiter, followed by measurement of serum TSH to determine thyroid functional status. 1, 2

• Measure serum TSH first to assess whether the patient is euthyroid, hypothyroid, or thyrotoxic, as this fundamentally determines the management pathway 1, 3
• Perform thyroid ultrasound to confirm the thyroid origin of the neck mass, characterize goiter size and morphology (diffuse vs. nodular), and identify any suspicious nodules requiring biopsy 1, 2, 4
• Add CT scan without IV contrast if there is substernal extension suspected or if the patient has obstructive symptoms (dyspnea, orthopnea, dysphagia, stridor), as CT is superior to ultrasound for evaluating tracheal compression and retrosternal extension 1, 2, 4

Management Based on Clinical Presentation

Asymptomatic Euthyroid Goiter

Most patients with asymptomatic euthyroid goiter require no treatment after malignancy is ruled out through appropriate evaluation. 5, 6

• Observation with periodic follow-up is appropriate for asymptomatic patients with benign cytology, including neck palpation and ultrasound examination 6
• Fine-needle aspiration biopsy should be performed on nodules >1 cm or smaller nodules with suspicious ultrasound features (hypoechogenicity, microcalcifications, irregular borders, absence of peripheral halo) to exclude malignancy 1, 7
• Levothyroxine suppression therapy should NOT be routinely recommended for simple nodular goiter, as evidence does not support its routine use and it risks iatrogenic hyperthyroidism 5, 8

Symptomatic Goiter with Compressive Symptoms

Surgery is the first-line treatment for goiters causing compressive symptoms such as dyspnea, orthopnea, dysphagia, or dysphonia. 9, 3

• Total or near-total thyroidectomy is recommended for symptomatic goiters, particularly those with substernal extension causing tracheal compression 9
• Preoperative CT imaging should be obtained to define the degree of tracheal compression and plan the surgical approach, especially for substernal goiters 1, 2
• Radioactive iodine therapy is an alternative to surgery if the goiter demonstrates adequate radioiodine uptake, and is commonly used in Europe as a safe and effective option 5, 6

Toxic Multinodular Goiter (with Thyrotoxicosis)

Radioactive iodine therapy or surgery are the definitive treatment options for toxic multinodular goiter. 1, 3

• Radionuclide uptake and scan with I-123 should be performed to confirm autonomous function and identify hyperfunctioning nodules 1, 4
• Radioiodine ablation is the therapy of choice for hot nodules causing thyrotoxicosis 5, 3
• Surgery is indicated if radioiodine is contraindicated or if there are compressive symptoms requiring urgent intervention 3

Critical Considerations for Malignancy Risk

Malignancy is equally common in multinodular goiter as in solitary nodules (approximately 5%), requiring the same vigilance for cancer detection. 5, 6

• Fine-needle aspiration biopsy is indicated for any nodule >1 cm or smaller nodules with suspicious ultrasound features, even within a multinodular goiter 7, 6
• Rapid growth of goiter increases suspicion for malignancy, particularly anaplastic transformation, and may require core or surgical biopsy 7
• Surgery is mandatory for nodules with malignant cytology or suspicious (indeterminate) cytology unless autonomous function can be confirmed by scintigraphy 1, 6

Special Clinical Scenarios

Substernal Goiter with Respiratory Distress

CT scan is essential for evaluating substernal extension and degree of tracheal compression in patients with respiratory symptoms. 1, 2

• Retrosternal extension into the mediastinum can cause significant tracheal compression leading to dyspnea, orthopnea, and obstructive sleep apnea 2
• MRI is an alternative to CT but is less preferred due to greater respiratory motion artifact 1, 4
• Surgical intervention should not be delayed in patients with significant respiratory compromise from tracheal compression 9

Goiter in Iodine-Deficient Regions

Iodine supplementation may be considered in regions with documented iodine deficiency, though this is less relevant in developed countries with adequate dietary iodine 3

Common Pitfalls to Avoid

• Do not rely on imaging alone (CT or MRI) to differentiate benign from malignant nodules, as these modalities cannot reliably predict malignancy without tissue diagnosis 1, 4
• Avoid routine levothyroxine suppression therapy as it lacks evidence for efficacy and risks causing iatrogenic hyperthyroidism, particularly in elderly patients 5, 8
• Do not assume multinodular goiter is benign without appropriate evaluation, as cancer risk is equivalent to solitary nodules 5, 6
• Measure serum calcitonin as part of the diagnostic evaluation to screen for medullary thyroid cancer, which has higher sensitivity than fine-needle aspiration for this diagnosis 1