Can a euthyroid patient with a multinodular nontoxic goiter be cleared for thyroidectomy if there are no other medical contraindications?

Preoperative Clearance for Multinodular Nontoxic Goiter in Euthyroid Patients

Yes, a euthyroid patient with multinodular nontoxic goiter can be cleared for thyroidectomy if there are no other medical contraindications, with the decision primarily driven by the presence of compressive symptoms, concern for malignancy based on fine-needle aspiration results, or cosmetic concerns. 1

Indications for Surgery

The decision to proceed with thyroidectomy in nontoxic multinodular goiter depends on specific clinical criteria:

Absolute Indications

• Malignant or suspicious cytology on fine-needle aspiration - Patients with nodules yielding malignant cytology should be referred for surgery 1
• Indeterminate (suspicious) cytology - Unless autonomous function can be confirmed by scintigraphy, surgery is generally advised, though most will ultimately prove benign 1
• Compressive symptoms - Dysphagia, choking sensation, airway obstruction, or other pressure symptoms warrant surgical intervention 1, 2

Relative Indications

• Large goiter size - Even benign but large goiters causing clinical symptoms require surgery for symptom alleviation 1
• Cosmetic concerns - Significant cosmetic deformity may justify surgical intervention 2

Preoperative Evaluation Required

Before clearing for surgery, ensure completion of:

• Serum TSH measurement - Confirms euthyroid status and excludes toxic multinodular goiter 1, 2
• Neck ultrasound - Evaluates number, size, and sonographic features of nodules 1
• Fine-needle aspiration biopsy - For prominent palpable or sonographically suspicious nodules 1, 2
• Chest radiography or CT - When substernal extension or tracheal compression is suspected 3, 2
• Vocal cord assessment - Consider evaluation of vocal cord mobility in patients with abnormal voice or invasive disease 3

When Surgery Can Be Avoided

Asymptomatic patients with benign cytology may be observed with periodic follow-up including neck palpation and ultrasound examination 1. In these cases:

• Yearly evaluation with serum TSH and thyroid palpation is sufficient for small, stable goiters 2
• Levothyroxine suppression therapy is controversial and often unsuccessful, with potential for adverse effects from exogenous hyperthyroidism 2

Alternative to Surgery

For elderly patients or those with significant cardiopulmonary comorbidities who refuse or cannot tolerate surgery:

• Radioactive iodine (¹³¹I) therapy is safe and effective, achieving mean thyroid volume reduction of 40% at 1 year and 50-60% at 3-5 years 4
• This approach results in approximately 20-30% incidence of hypothyroidism at 5 years and ~5% risk of autoimmune hyperthyroidism 4
• The estimated lifetime risk of fatal/nonfatal cancer from ¹³¹I therapy is approximately 0.5% in elderly patients 4

Surgical Considerations

When proceeding with surgery:

• Refer to high-volume surgeons - High-volume surgeons (>100 cases/year) have significantly lower complication rates (4.3%) compared to low-volume surgeons (<10 cases/year) (17.2%) 5
• Counsel on complications - Permanent recurrent laryngeal nerve injury occurs in 3% and permanent hypoparathyroidism in 2.6% after total thyroidectomy 5
• Anticipate technical challenges - Very large goiters (>1-2 kg) require experienced surgical teams prepared for potential tracheomalacia, difficult intubation, and possible need for tracheostomy 6

Common Pitfalls to Avoid

• Do not use levothyroxine suppression in patients with suppressed TSH - This risks development of toxic symptoms 2
• Do not assume all nodules in multinodular goiter are benign - Approximately 5% may harbor malignancy, necessitating selective FNA of suspicious nodules 1
• Do not delay surgery in symptomatic patients - Compressive symptoms warrant definitive surgical management rather than prolonged observation 1, 2