Multinodular Goitre

Background

• Common cause of hyperthyroidism.  However, many patients will present euthyroid with a multinodular goitre
• More common with increasing age (more common in patients who have had a diffuse goitre in early adulthood in the absence of autoantibodies)

Clinical Presentation

• Commonly patients will present hyperthyroid
  • They may have a large, nodular/lobulated goitre
    • Can present with a painful swelling (caused by haemorrhage into a nodule)
    • There may be associated symptoms e.g. dysphagia, stridor, hoarseness (although if this is present, consider cancer > goitre)

Investigations

• TFTs
  • TSH is almost always suppressed
  • Because the remainder of the thyroid is normal (and therefore won’t be producing thyroid hormone), T3/T4 levels can be normal (depending on the number of nodules) or elevated (toxic disease)
• Thyroid scintigraphy

Management

• In toxic disease, radioactive iodine is the treatment of choice (although at a much higher dose than in Graves’ disease)
  • This is also used more routinely for patients with subclinical disease (suppressed TSH a risk factor for AF and osteoporosis)
• Surgery can be considered for those with large goitres causing tracheal/mediastinal compression (rare) or which are cosmetically unattractive (although often second to radiation therapy)