Management

Diffuse, non-toxic goitre - small goitres usually require little treatment apart from reassurance and possibly iodine supplements. Large goitres may be treated by subtotal thyroidectomy since thyroxine causes shrinkage in less than 30% of cases.

The treatment of choice for thyrotoxicosis caused by thyroid nodular disease is radio-iodine (2,4):

• adults with toxic nodular goitre
  • offer radioactive iodine as first-line definitive treatment for adults with hyperthyroidism secondary to multiple nodules unless it is unsuitable (for example, there are concerns about compression, thyroid malignancy is suspected, they are pregnant or trying to become pregnant or father a child within the next 4 to 6 months, or they have active thyroid eye disease)
  • offer total thyroidectomy or life-long antithyroid drugs as first-line definitive treatment for adults with hyperthyroidism secondary to multiple nodules if radioactive iodine is unsuitable
  • offer radioactive iodine (if suitable) or surgery (hemithyroidectomy) as firstline definitive treatment for adults with hyperthyroidism secondary to a single nodule, or life-long antithyroid drugs if these options are unsuitable.

Multinodular goitre - thyroxine is often successful in preventing progression and occasionally, in causing regression. Surgery is indicated if (1):

• there is retrosternal extension
• there is dysphagia attributed to the goitre
• there is marked tracheal deviation or stenosis
• there is a recurrent laryngeal palsy
• the goitre is cosmetically unacceptable
• the patient is hyperthyroid but radio-iodine is unsuitable (4)

A total thyroidectomy with lifelong thyroxine may be indicated if there is no normal thyroid tissue.

Solitary "cold" nodules - may be removed for cosmetic reasons or if shown to be malignant.

Solitary "hot" nodules - may be excised if associated with hyperthyroidism.

NICE state with respect to managing non-malignant thyroid enlargement (4):

Do not offer treatment to adults with non-malignant thyroid enlargement, normal thyroid function and mild or no symptoms unless:

• they have breathing difficulty or
• there is clinical concern, for example, because of marked airway narrowing.

Repeat thyroid ultrasound and TSH measurement for adults with non-malignant thyroid enlargement who are not receiving treatment, if:

• malignancy is subsequently suspected,
• or compression is suspected

Consider repeating thyroid ultrasound and TSH measurement for adults with non-malignant thyroid enlargement who are not receiving treatment, if:

• the person's symptoms worsen or
• they develop symptoms, such as hoarseness, or shortness of breath

For children and young people with non-malignant thyroid enlargement and normal thyroid function, discuss management with a specialist multidisciplinary team.

For adults with normal thyroid function and a cyst or predominantly cystic nodule with no vascular components, offer aspiration if it is causing compressive symptoms, with possible ethanol ablation if there is re-accumulation of cyst fluid later.

For adults with normal thyroid function and a non-cystic nodule or multinodular or diffuse goitre, consider the following if they have compressive symptoms relating to thyroid enlargement:

• surgery, particularly if there is marked airway narrowing or
• radioactive iodine ablation, if there is demonstrable radionuclide uptake, or
• percutaneous thermal ablation

Reference:

• (1) Young, A. Goitre. Surgery 1994;12:5: 111-116
• (2) Franklyn JA.The management of hyperthyroidism. NEJM 1994;330: 1731-8.
• (3) Goiter: Medical Content Of The American Thyroid Association 2006
• (4) NICE (November 2019). Thyroid disease: assessment and management