MULTINODULAR NON-

TOXIC GOITER
PGI Joseph D. Causapin
 OBJECTIVES
q Review on anatomy and physiology of the thyroid
gland

q Present a case of 35- yr old female patient with

Multinodular Non- toxic Goiter

q Discuss the pathogenesis, clinical features and

treatment of MNTG.
ANATOMY
THYROID GLAND
 THYROID GLAND
q The thyroid is composed of two
lateral lobes connected by an
isthmus, which rests at the level of
the 2nd- 4th tracheal cartilages.
q Each thyroid lobe measures
approximately 4 cm high, 1.5 cm
wide, and 2 cm deep.
q A pyramidal lobe, a remnant of
descent of the thyroid is present in
up to 40% of patients.
 THYROID GLAND
610 Pa rt 4: Head

BLOOD SUPPLY
q SUPERIOR THYROID ARTERY
q INFERIOR THYROID ARTERY
q THYROIDEA IMA
VENOUS DRAINAGE

q SUPERIOR THYROID VEINS

q MIDDLE THYROID VEINS
q INFERIOR THYROID VEINS
 THYROID GLAND 610 Pa rt 4: Head

LYMPHATICS
qThe isthmus and medial thyroid
lobes àDelphian, pretracheal, and
superior mediastinal nodes
qLateral thyroid à internal jugular
chain.
qThe inferior pole à paratracheal,
perirecurrent laryngeal nerve (RLN)
nodes.
 THYROID GLAND 608 Pa rt 4: H
NERVE SUPPLY
qThe SLN arises rom the upper vagus nerve
and descends medial to the carotid sheath.
It divides into internal and external branches
about 2 to 3 cm above the superior pole of
the thyroid.

qThe RLN provides motor innervation

(branchial efferents) to the inferior constrictor
and all intrinsic laryngeal muscles except the
cricothyroid muscle.
THYROID HORMONES
Thyroid gland produces two related hormones:
THYROID GLAND
thyroxine (T4) and triiodothyronine (T3)
 THYROID HORMONE
FUNCTIONS

growth and maturation of tissues

cell respiration and total energy

expenditure

turnover of substrates, vitamins,

hormones (including thyroid
hormones)
612 Pa rt 4: Head and Neck

PATTERNS OF THYROID FUNCTION TEST

TABLE 33-1 Patterns O T yroid Function ests
Euthyroid Hyperthyroid Hypothyroid States o High BG States o Low BG
SH Normal ↓ ↑ Normal Normal
otal 4
Normal ↑ ↓ ↑ ↓
3
resin uptake (or HBR) Normal ↑ ↓ ↓ ↑
Free 4
index Normal ↑ ↓ Normal Normal
BG, thyroid-binding globulin; SH, thyroid-stimulating hormone; , thyroxine;
4
, triiodothyronine.
3

Benign T yroid Disease

Hypothyroidism
• Hypothyroidism is the unctional state characterized by increased SH and
decreased H.
• Hypothyroidism has a variety o causes and can present with a multitude o symptoms
The CASE

Consult was done to

35- year old 3- year history of Mass was noted to an AP, biopsy and
woman no co- anterior neck increase in size neck ultrasound were
mass; soft, non- extending laterally, requested which
morbidities and revealed multiple
tender and moves right side is bigger
other medical thyroid nodules with
during swallowing. than the left. cystic degeneration.
conditions.
 PAST MEDICAL
H I S T O R Y

(-) HPN
(-) DM
(-) BA
(+) Cesarean Section X 2
(2014, 2016- CLMMRH)
(+) Bilateral Tubal Ligation-
2016
 PERSONAL SOCIAL
H I S T O R Y

(-) Smoker
(-) Alcoholic Beverage Drinker
(-) illicit drug use
Works as policewoman in
Bacolod City
 REVIEW OF
S Y S T E M S
General: (-) insomnia, (-) irritability
Gastrointestinal: (-) vomiting, (-) loose bowel
Skin: (-) dry skin, (-) crusted skin lesions
movement, (-) constipation, (-) loss of
Head and Neck: (-) headache, (-) dizziness,
appetite
(-) deformities Urinary: (-) pain, (-) frequency, (-) hematuria
Eyes: (-) redness, (-) tearing, (-) pain
Genital: (-) discharge, (-) lumps, (-) pain
Ears: (-) tinnitus, (-) infection, (-)
Peripheral Vascular: (-) edema, (-) cramps, (-)
discharges, (-) earache claudication
Nose and Sinuses: (-) cold, (-) discharge, (-)
Neurologic: (-) seizures, (-) tremors, (-)
congestion numbness
Mouth and Throat: (-) difficulty of
Hematologic: (-) easy bruising, (-) bleeding
swallowing Endocrine: (-) heat/cold intolerance
Respiratory: (-) cough
Psychiatric: (-) hallucination, (-) illusion, (-)
Cardiovascular: (-) edema, (-) chest pain
mood disorder
PHYSICAL EXAMINATION
soft, warm to touch, good skin turgor, (-)
jaundice, (-) hematoma noted. Pinkish nail
beds, (-) discoloration, (-) clubbing of nails.
Skin and Nails

Anicteric sclerae, pink conjuctivae, (-) sinus

tenderness, (-) ear discharges, (-)
Lymphadenopathies
(+) Anterior neck mass 4x5 cm right, 2x3
HEENT cm left; soft, non- tender, moves with
swallowing
 PHYSICAL EXAMINATION
Normal antero-posterior diameter, Carotid pulse upstroke is brisk and tapping. No
symmetric with no deformities, (-) neck vein engorgement.
unilateral lagging.
Cardiovascular
No tenderness or masses noted. PMI is brisk
Thorax
Trachea is at midline, symmetrical and tapping noted at 5th intercostal space MCL
chest expansion. at around 2.5 cm. No heaves, thrills and lifts.

Clear breath sounds heard on all lung Heart rate is normal with regular rhythm. Heart
fields. sounds are on regular intensity and duration
with no audible S3 and S4. At the base S2 is
louder than S1, while at the apex, S1 is louder
than S2. No murmurs or extra hearts sounds.
 PHYSICAL EXAMINATION
Abdominal wall shows flat contour, not
distended, centrally- located (+) Full ROM for right upper and
umbilicus. No striae, scars or lower extremities, (+) weakness of
prominent venous pattern. the left side of the body (-)
Abdomen MSK tenderness
Normoactive bowel sounds (26
clicks/min.
Diffuse tympanitic abdomen upon
percussion with scattered areas of Good capillary refill time of <2
dullness on the RUQ. secs, (+) Apulses on all extremities.

No palpable abdominal masses. The PVS

spleen and the lower edge of the liver
were not palpable and no evidence of
hernia.
 PHYSICAL EXAMINATION
MSE: Awake, coherent, and oriented to time, place, person.

CRANIAL NERVES:
CN 1: not tested
CN 2: pupils equally round and reactive to light at 2 mm
CN 3,4, 6- intact EOM’s
CN 5- intact chewing mechanism on both sides,
CN 7- intact motor and sensory functions
CN 8- intact sensory functions
CN 9, 10- intact motor and sensory functions
CN 11- intact motor functions
CN 12- intact motor function
PHYSICAL EXAMINATION
Muscle Strength Sensory

5/5 5/5 100% 10%

100% 70%
5/5 5/5
PHYSICAL EXAMINATION
DEEP TENDON REFLEXES: MENINGEALS:

(-) nuchal rigidity

(-) Brudzinski sign
2+ 2+ (-) Kernig’s sign

CUTANEOUS STIMULATION:
2+ 2+ (-) Babinski
 SALIENT FEATURES
HISTORY P.E.
ü35/F üAnterior neck mass; soft,
üAnterior neck mass non- tender and moves
SYSTEMIC LUPUS
ü(-) no maintenance
medications
during swallowing
ü(-) cervical
ERYTHEMATOSUS
ü(+) episodes of dysphagia lymphadenopathy
ü(-) facial paresis

(SLE)
 DIAGNOSIS
MULTINODULAR
NON- TOXIC GOITER
DISCUSSION
MULTINODULAR NON- TOXIC GOITER
q Nontoxic goiter may be defined as any thyroid enlargement
that is characterized by uniform or selective (i.e., restricted to
one or more areas) growth of thyroid tissue, is not associated
with overt hyperthyroidism or hypothyroidism, and does not
result from inflammation or neoplasia.

q A thyroid nodule is defined as a discrete lesion, within the

thyroid gland, due to an abnormal, focal growth of thyroid
cells.
 ETIOPATHOGENESIS

PUBERTY Feedback in TSH Hypertrophy

of the gland
PHYSIOLOGIC GOITER

IODINE DEFICIENCY DYSHORMOGENESIS GOITROGENS RADIATION EXPOSURE

ETIOPATHOGENESIS
 STAGES OF GOITER FORMATION
STIMULATION DIFFUSE HYPERPLASTIC GOITRE
(reversible if stimulation ceases)

MIXED PATTERN with areas of active &

inactive lobules
Continual repetition of this (as a result of fluctuating stimulation)
goiter process results in a
nodular

Necrotic lobules coalesce to

form nodules filled either with Active lobules bcom more vascular &
iodine free colloid or a mass of hyperplastic until hemorrhage occurs,
new but inactive follicles causing central necrosis .
 CLINICAL FEATURES

Hypothyroidic
MASS EFFECT
e.g. dyspnea,
Cosmetic Mostly
presentations
dysphagia, effects euthyroid , may
in specific
hoarseness, present with
compression of clinical
the great vessels
hyperthyroidism
settings
(SVC syndrome) (toxic MNG)
EVALUATION
DIAGNOSTIC INVESTIGATION
 DIAGNOSIS
q Thyroid function tests
q Ultrasonography (USG)
q Fine needle aspiration cytology (FNAC)
q Complete blood picture (CBC)
q X-ray neck :AP & Lateral view
q CT scan : to look for retrosternalextension
q Thyroid scan-contains radioactive Iodine
 Laboratory studies
DIAGNOSIS
Thyroid function TSH(0.3-5IU/ml)
 Serum
tests
 Serum T3(1.5-3.5nmol/l)
qSerum TSH: (0.3-5IU/ml)
 Serum
qSerum T3:T4(55 – 150nmol/l)
(1.5-3.5nmol/l)
qSerum T4: (55 – 150nmol/l)
Disease T3 T4 TSH

Thyrotoxicosis Increased Increased Supressed

T3 toxicosis 2X Normal Suppressed

Hypothyroidism Low/normal Low Increased

 DIAGNOSIS
Thyroid function tests

qTSH ASSAY- the sole test necessary to sensitively diagnose

hypo- or hyperthyroidism
q Serum anti-TPO antibody (TPO Ab)
 DIAGNOSIS
NECK ULTRASOUND
q allows the health care provider to
assess both the morphologic
appearance and the size of the gland,
while also assessing cancer risk in
thyroid nodules
q capable of detecting even minute
thyroid nodules.
q can identify the number, size, and
shape of cervical nodes surrounding
and distant from the thyroid.
 1. Patients ound to have thyroid nodules greater than 1-1.5 cm should undergo a complete history, physical
examination, and measurement o serum SH.

hyperthyroidism. DIAGNOSIS
2. I low SH, then I123 or c99 scanning, i uni orm increased uptake or “hot” then evaluate and treat or

3. Normal or elevated SH, proceed with ultrasound (U/S).

FINE
4. I NEEDLE ASPIRATION
no nodule is seen sonographicallyBIOPSY
and SH is high then evaluate and treat hypothyroidism; i SH is normal
then no urther workup.
qUltrasound guided
5. I U/S shows a posterior nodule,FNAB
a nodule is thethan
greater recommended
1-1.5 cm, or a nodule greater than 50% cystic then U/S
guided FNA should be per ormed.
diagnostic of choice for evaluation of thyroid nodules.
6. FNA results:
A. Nondiagnostic/inadequate: repeat U/S-guided FNA in 3 months, i inadequate again, then close ollow-up
or surgery.
B. Malignant: surgery
C. Indeterminate: I suspect carinoma then surgery; i suspect neoplasia then consier I123, hot nodules are
ollowed, cold nodules should proceed to surgery.
D. Benign: It is recommended that nodules ound to be benign on FNA and are easily palpable be ollowed
clinically at 6-18 month intervals. Benign nodules not easily palpated should be ollowed with U/S at the
same ollow-up intervals. I there is evidence o benign nodule growth repeat FNA with U/S guidance is
recommended.
7. Cysts less than 4 cm can be aspirated and potentially suppressed, with surgery reserved or recurrent cyst
ormation. Cysts larger than 4 cm should be resected.
MANAGEMENT
The Journal of Clinical
Endocrinology &
Metabolism, Volume 96,
Issue 5, 1 May 2011,
Pages 1202–
1212, https://doi.org/10.1
210/jc.2010-2583
 HISTORY AND
HYPERTHYROID
PHYSICAL
EXAMINATION MULTINODU
LAR HYPOTHYROID

EUTHYROID

THYROID SOLITARY SMALL / SUBSTERNAL/

ENLARGEMENT ASYMPTOMATIC COMPRESSIVE
SYMPTOMS

LABORATORY Serial Exams BARIUM SWALLOW

ü sTSH TSH suppression FLOW VOLUME
ü FT4, T3 DIFFUSE Ultrasound
ü FNAB LOOP
ü Neck Utz
ü CT/ MRI
ü Radionuclide
Imaging SURGERY
 TREATMENT
q In the early stages a hyperplastic goiter may regress if thyroxine is given
in a dose of 0.15-0.2 mg daily for few months.

q Although the nodular stage is irreversible , more than half of benign

nodules will regress in size over years.

q Most of the MNTG are asymptomatic and do not require operation.

q Operation may be indicated on cosmetic grounds, for pressure

symptoms, or in response to patient anxiety.

q Retrosternal extension is an indication for thyroidectomy.

 TREATMENT
q When entire gland Is involved – total thyroidectomy is better

q Subtotal thyroidectomy is done depending on the amount of gland

involved, location 8gms of thyroid tissue is retained in each lateral lobe

q Often partial thyroidectomy or Harley dunhill operation (one lateral lobe

+ isthmus+ opp side subtotal or partial)

q Reoperation for recurrent nodular goiter is more difficult and

hazardous and for this reason, total thyroidectomy is favored in
younger patients.
OPERATIVE TECHNIQUE
TOTAL THYROIDECTOMY
TOTAL THYROIDECTOMY

A collar-type thyroid incision is made, typically 1 or 2 finger

breadths above the sternal notch in a curvilinear fashion,
with in a normal skin crease. A subplatysmal skin flap is
raised superiorly up to the level of the thyroid notch.
 TOTAL THYROIDECTOMY

A collar-type thyroid incision is made, typically 1 or 2

finger breadths above the sternal notch in a
curvilinear fashion, with in a normal skin crease. A
subplatysmal skin flap is raised superiorly up to the
level of the thyroid notch.
 TOTAL THYROIDECTOMY

A subplatysmal skin flap is raised superiorly Strap muscles are identifed in the
up to the level of the thyroid notch. midline, and the sternohyoid (more
medial) and sternohyoid (more lateral)
are elevated in one layer o the ventral
surface of the thyroid lobe.
TOTAL THYROIDECTOMY
The rough primarily blunt dissection, the
lobe is dissected and mobilized. As this
is done, the thyroid gland is retracted
medially, and the strap muscles are
retracted laterally.
The middle thyroid vein should be
ligated, providing lateral exposure of
the middle lobe.
TOTAL THYROIDECTOMY
The inferior pole is dissected with an eye toward
identifying the inferior parathyroid, which is typically
located within 1 cm inferior or posterior to the
thyroid’s inferior pole. The inferior parathyroid is
often within the uppermost thyrothymic horn (upper
thymus).
 TOTAL THYROIDECTOMY
q The RLN can be identifed through the lateral approach at the midpolar
level just below the ligament of Berry and its laryngeal entry point or
medial to the tubercle of Zuckerkandl.
q The RLN is identifed as a white, wave-like structure with characteristic
vascular stripe. Extralaryngeal branching can occur in about one-third of
patients above the crossing point of the RLN and inferior thyroid artery.
On the right, the RLN angles more laterally than on the le. Nerve
stimulation can be used to facilitate nerve identification.
q The laryngeal entry point is indicated by the inferior cornu to the thyroid
cartilage.
q The possibility of a nonrecurrent RLN on the right should be kept in
mind.
q Goitrous enlargement of the thyroid gland can significantly distort RLN
position, as can peri-RLN nodal paratracheal disease.
 TOTAL THYROIDECTOMY
q Downward and lateral retraction o the superior pole allows
dissection in the interval between the thyroid cartilage medially
and the superior pole laterally (cricothyroid space).
q The superior polar vessels are then ligated at the level o the thyroid
capsule. The external branch of the SLN can be, in approximately
20% of cases, closely related to the superior pole vessels at the
level of the thyroid capsule and therefore vulnerable to injury.
q In those cases where a portion o the lobe is le in place in order to
preserve parathyroid tissue, it is the posterolateral portion of the
thyroid lobe that should be left in situ.
 POST- OP COMPLICATIONS
q Bleeding
q Infection
q RLN paralysis
q Temporary/ permanent hypocalcemia-
hypoparathyroidism
q Need for life long thyroid supplements like L-thyroxine
 TAKE- HOME POINTS
q Thyroid enlargement without significant functional derangement may occur with diffuse
enlargement or through multinodular formation (multinodular goiter).

q Goiter development can be sporadic or associated with iodine deficiency, inherited

metabolic defects, or exposure to goitrogenic agents.

q Thyroid unction tests are normal or nontoxic diffuse goiter. For multinodular goiter,
thyroid function tests may show a normal T4 and T3, with TSH low normal as some of the
nodules slowly grade toward autonomy.

q Goiter maybe stable over a period of years or can slowly grow. Nodules within
multinodular goiter may also undergo rapid, painful enlargement secondary to
hemorrhage. Such a rapid increase in size may be associated with pain and an increase in
regional symptoms, including airway distress.
 TAKE- HOME POINTS
q Several studies suggest that from 15% to 45% of patients with large cervical goiters of
substernal goiters maybe asymptomatic. Of note, patients maybe asymptomatic and yet
have radiographic evidence of tracheal compression and evidence of airway obstruction
on flow volume studies.

q When patients with goiter are symptomatic, they may present with chronic cough,
nocturnal dyspnea, choking, and difficulty breathing in different neck positions or in
recumbency. Several surgical series show that approximately 20% of patients with cervical
and retrosternal goiters present with acute airway distress, with up to 10% requiring
intubation.

q Surgical consideration should be given to all patients who are symptomatic, all patients
with significant radiographic evidence of airway obstruction, and all patients with
substernal goiter should be offered surgery.
 TAKE- HOME POINTS
q Other surgical indications include significant cosmetic issue and all substernal
goiters, as the substernal tissue represents abnormal tissue, which is unavailable
for routine physical examination, monitoring, or FNA.

q The physical examination of such patients should include evaluation of respiratory

status, tracheal deviation, and substernal.

q All patients should have vocal cord mobility assessed.

q All patients should have a TSH test to rule out subclinical hyperthyroidism.
 TAKE- HOME POINTS
q Ultrasound should be performed even when multiple nodules are present. It is
recommended that nodules measuring 1.0 to 1.5 cm, those with suspicious
sonographic appearance such as micro calcification and intranodular
hypervascularity should be aspirated as should isofunctioning or non functioning
nodules, especially those with suspicious sonographic features.

q If there is significant concern regarding tracheal deviation, compression or

substernal extension an axial CT scan should be performed.

q Thyroxin suppression can reduce goiter size and has been found to be more
helpful in diffuse than in multinodular goiter. The reduction in goiter size is,
however, unpredictable. Goiter growth typically resumes after T4 discontinuation.
 TAKE- HOME POINTS
q During the surgery or goiter, nerve identification is of course
necessary as in all cases of thyroidectomy. It may be necessary to use
a superior approach with identification of the nerve at the laryngeal
entry point after superior pole dissection and then retrograde
dissection of the nerve.

qSub- total thyroidectomy, may rarely be appropriate depending on

intraoperative parathyroid findings in order to preserve parathyroid
tissue. The incidence of carcinoma (usually small intrathyroidal
papillary carcinomas) in such multinodular goiters is approximately
7.5%.
 13TH EDITION

WILLIAMS textbook of

ENDOCRINOLOGY
Shlomo Melmed, MBChB, MACP
Professor of Medicine
Senior Vice President and Dean of the Medical Faculty
Cedars-Sinai Medical Center
Los Angeles, California

Kenneth S. Polonsky, MD
Richard T. Crane Distinguished Service Professor
Dean of the Division of the Biological Sciences and the Pritzker School of Medicine
Executive Vice President for Medical Affairs
The University of Chicago
Chicago, Illinois

P. Reed Larsen, MD, FRCP

Professor of Medicine
Harvard Medical School
Senior Physician
Division of Endocrinology, Diabetes, and Metabolism
Brigham and Women’s Hospital
Boston, Massachusetts

Henry M. Kronenberg, MD
Professor of Medicine
Harvard Medical School
Chief, Endocrine Unit
Massachusetts General Hospital
Boston, Massachusetts

REFERENCES
THANKYOU