Toxic Multinodular Goiter

Answer: b



Hyperthyroidism in the patient with a multinodular goiter usually develops in women after age 50 but is seen occasionally in younger patients. Most patients have had a nontoxic nodular goiter for many years. Preferred treatment for most patients with toxic multinodular goiters is thyroidectomy after adequate preparation renders the patient euthyroid. 131I may be an alternative in selected poor-risk patients with goiters that are not causing airway compression. Although 131I can be used to treat the hyperthyroidism, larger and often repeated doses of 131I may be required. 131I does not significantly reduce the goiter size and may, because of radiation-induced thyroiditis, cause acute enlargement. This may be hazardous in the patient with some degree of preexisting airway compression. Any airway symptoms, particularly in patients with substernal goiters, should be considered strong contraindications to the use of 131I.

Standard surgical treatment of toxic nodular goiter has consisted of bilateral subtotal thyroidectomy. Remnant size is not as important as the excision of all autonomous nodules. Because thyroid replacement or suppression is used routinely to prevent recurrence of goiter when a subtotal resection is done, the risk of hypothyroidism is not a consideration in determining remnant size. Alternative procedures are total lobectomy with isthmus resection and contralateral subtotal lobectomy, or total thyroidectomy. The latter is not demonstrably superior and may have more technical complications.

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