eMedicine Specialties > Endocrinology > Thyroid

Goiter: Follow-up

Author: James R Mulinda, MD, FACP, FACE, Consulting Staff, Department of Endocrinology, Endocrinology Associates, Inc
Contributor Information and Disclosures

Updated: Aug 18, 2009

Follow-up

Further Inpatient Care

  • Preoperative management
    • Establish euthyroid state prior to surgical treatment.
    • Evaluation must include the stability of the airway. This must be secured immediately if ventilatory status appears tenuous.
    • Emergency surgical treatment of a goiter in a patient with hypothyroidism requires intravenous levothyroxine and glucocorticoids at stress doses.
    • Emergency surgical treatment of a goiter in a thyrotoxic patient requires antithyroid medications, beta-blockers, and glucocorticoids at stress doses. Suppressive doses of iodine are helpful.
  • Intraoperative and postoperative management: Hemodynamic monitoring is important in patients with preoperative hyperthyroidism or hypothyroidism.
  • Postoperative management also includes monitoring of serum calcium.

Further Outpatient Care

Patients are monitored for hypothyroidism by history, examination, and TSH measurements. Initially, monitoring occurs every 6-8 weeks.

Inpatient & Outpatient Medications

Benign euthyroid goiters do not require any medication. Goiters with primary thyroid malignancy require levothyroxine replacement after surgery and radioactive iodine ablation. Metastatic lesions to the thyroid gland require treatment of the primary malignancy. Granulomatous and infectious etiologies for goiter require specific treatment depending on the underlying cause.

Deterrence/Prevention

  • Goiter prevention is based on etiology.
    • Correct iodine deficiency1 and avoid dietary or iatrogenic goitrogens if practical. In the United States, it is difficult to find iodine deficiency, given the supplementation of table salt with iodine, iodine in cattle feed, and the use of iodine as a dough conditioner. Judicious use of levothyroxine is helpful in patients with a previous diagnosis of nodular hyperplasia who have had a lobectomy to prevent occurrences in the contralateral lobe.
    • Goiters due to autoimmune thyroiditis may be controlled with careful use of levothyroxine and, when indicated, anti-inflammatory medication.
    • Congenital goiters due to inborn errors of metabolism may be reduced or prevented by careful use of levothyroxine during the postpartum period. Newborns are screened for congenital hypothyroidism.

Complications

  • Large goiters may cause compression of the trachea, with tracheomalacia and asphyxiation.
  • Hyperthyroidism occurs in some patients exposed to iodine (ie, Jodbasedow phenomenon).
  • A patient with autoimmune goiters may develop lymphoma. Multinodular goiters may undergo malignant transformation.
  • Nodular goiters may cause pain, intranodular necrosis, or hemorrhage.
  • Thyroid abscess may be associated with pain, fever, bacteremia, or sepsis.

Prognosis

  • Benign goiters have a good prognosis. However, all goiters should be monitored by examination and biopsy for possible malignant transformation, which may be signaled by a sudden change in size, pain, or consistency. Fortunately, the risk of this is low. In patients exposed to low levels of radiation the risk rises.
  • Based on the Wickham study, a few of the goiters increased in size.2
  • A small percentage of multinodular goiters do cause hyperthyroidism. Lifelong surveillance is necessary.
  • Patients with chronic lymphocytic thyroiditis generally have glands that become atrophic.

Patient Education

  • Educate a patient about potential etiologies, eg, adequate dietary iodine intake, avoidance of goitrogens, regular personal neck examination, and physician examination.
  • For patients on medical therapy, reinforce the need to take medications on a regular basis. Review symptoms of hyperthyroidism.
  • For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems.

Miscellaneous

Medicolegal Pitfalls

  • Autoimmune thyroiditis goiter may develop into thyroid lymphoma.
  • Evaluate a goiter with diastolic hypertension for pheochromocytoma.
  • A thyroid nodule could be a parathyroid tumor.
  • Pain and enlargement of a nodule may be due to hemorrhage or anaplastic carcinoma.
  • Rapid growth of the thyroid in a patient with extrathyroidal cancer may signal metastasis to the thyroid.
  • A goiter with prior radiation exposure may develop lymphoma.
  • Levothyroxine use for goiter control warrants close monitoring to avoid hyperthyroidism, arrhythmias, and osteoporosis.
  • Hyperthyroidism may masquerade as a papillary carcinoma.
  • Thyroid fine-needle aspiration becomes less reliable in large goiters because of sampling bias. Thyroid cysts should not be left without first detecting the underlying cause. Nondiagnostic biopsy findings should precipitate further investigation, which may include performing an additional biopsy or more invasive procedures, depending on the clinical situation.

Special Concerns

  • Withhold treatment of a benign euthyroid goiter in patients who are pregnant until after delivery.
  • Thyroidectomy, if necessary, can be more safely performed in the second trimester.
 
Acknowledgments

I acknowledge my mentors for the foundations, my patients for their contributions to my knowledge, and my family for their patience.



More on Goiter

Overview: Goiter
Differential Diagnoses & Workup: Goiter
Treatment & Medication: Goiter
Follow-up: Goiter
Multimedia: Goiter
References
Further Reading
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References

  1. Triggiani V, Tafaro E, Giagulli VA, et al. Role of iodine, selenium and other micronutrients in thyroid function and disorders. Endocr Metab Immune Disord Drug Targets. Sep 1 2009;[Medline].

  2. Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, et al. The spectrum of thyroid disease in a community: the Wickham survey. Clin Endocrinol (Oxf). Dec 1977;7(6):481-93. [Medline].

  3. Sawin CT, Geller A, Hershman JM, Castelli W, Bacharach P. The aging thyroid. The use of thyroid hormone in older persons. JAMA. May 12 1989;261(18):2653-5. [Medline].

  4. Guth S, Theune U, Aberle J, Galach A, Bamberger CM. Very high prevalence of thyroid nodules detected by high frequency (13 MHz) ultrasound examination. Eur J Clin Invest. Aug 2009;39(8):699-706. [Medline].

  5. Duarte GC, Tomimori EK, de Camargo RY, Catarino RM, Ferreira JE, Knobel M, et al. Excessive iodine intake and ultrasonographic thyroid abnormalities in schoolchildren. J Pediatr Endocrinol Metab. Apr 2009;22(4):327-34. [Medline].

  6. Pinchot SN, Al-Wagih H, Schaefer S, Sippel R, Chen H. Accuracy of fine-needle aspiration biopsy for predicting neoplasm or carcinoma in thyroid nodules 4 cm or larger. Arch Surg. Jul 2009;144(7):649-55. [Medline].

  7. Arda IS, Yildirim S, Demirhan B, Firat S. Fine needle aspiration biopsy of thyroid nodules. Arch Dis Chil. 2001;85(4):313-7. [Medline].

  8. Bardin CW. Endemic goiter. In: Current Therapy in Endocrinology and Metabolism. 6th ed. Mosby-Year Book; 1997:101-112.

  9. Becker KL, Bilezikian JP, Bremner WJ. Nontoxic goiter. In: Principles and Practice of Endocrinology and Metabolism. 2nd ed. Lippincott Williams & Wilkins; 1995:338-345.

  10. Bostanci I, Sarioglu A, Ergin H, Aksit A, Cinbis M, Akalin N. Neonatal goiter caused by expectorant usage. J Pediatr Endocrinol Metab. Sep-Oct 2001;14(8):1161-2. [Medline].

  11. Braverman LE, Utiger RD. Thyroid diseases: nontoxic diffuse and multinodular goiter. In: Werner and Ingbar, eds. The Thyroid: A Fundamental and Clinical Text. 7th ed. Lippincott-Raven; 1996:889-900.

  12. Gross JL. Ultrasonography in management of nodular thyroid disease. Annals of internal medicine. 2001;135(5):383-4. [Medline].

  13. Romanchishen AF, Iakovlev PN. [Special surgical treatment of patients with nodular tumors of the thyroid gland against the background of diffuse toxic goiter]. Vestn Khir Im I I Grek. 2005;164(1):21-4. [Medline].

  14. Sawin CT, Geller A, Wolf PA, et al. Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med. Nov 10 1994;331(19):1249-52. [Medline].

  15. Schumm-Draeger PM. [Every third German has a sick thyroid gland. Nodules and goiter are a challenge that needs to be met]. MMW Fortschr Med. Feb 5 2004;146(6):20. [Medline].

  16. Thompson L. Dyshormonogenetic goiter of the thyroid gland. Ear Nose Throat J. Apr 2005;84(4):200. [Medline].

  17. Vetshev PS, Chilingaridi KE, Bannyi DA, Dmitriev EE. [Repeated surgeries on the thyroid gland in nodular euthyroid goiter]. Khirurgiia (Mosk). 2004;37-40. [Medline].

  18. Wilson JD, Foster DW. The thyroid gland. In: Williams Textbook of Endocrinology. 8th ed. Harcourt Brace & Co; 1992:463-465.

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Further Reading

Clinical guidelines:
 American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules.
American Association of Clinical Endocrinologists - Medical Specialty Society
Associazione Medici Endocrinologi - Medical Specialty Society. 1996 Jan (revised 2006 Feb). 40 pages. NGC:004869

Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.
American Thyroid Association - Professional Association. 2006 Feb. 34 pages. NGC:005212

Screening for congenital hypothyroidism: U.S. Preventive Services Task Force reaffirmation recommendation statement.
United States Preventive Services Task Force - Independent Expert Panel. 1996 (revised 2008 Mar). 6 pages. NGC:006354

Clinical trials:
 rhTSH, Radioiodine Uptake and Goiter Reduction Following 131I Therapy in Patients With Benign Nontoxic Nodular Goiter

Block-Replacement Therapy During Radioiodine Therapy

Levothyroxine Treatment in Thyroid Benign Nodular Goiter

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Keywords

goiter, goiter disease, thyroid disease, thyroid cancer, iodine deficiency, hypothyroidism, hyperthyroidism, thyroid nodules, thyroid gland goiter, nontoxic goiter, toxic goiter, multinodular goiter, endemic goiter, Hashimoto disease, iodine, enlarged thyroid gland, inborn errors of thyroid hormone synthesis, goitrogens, TSH receptor antibodies, pituitary resistance to thyroid hormone, adenomas of hypothalamus, adenomas of pituitary gland, tumors producing human chorionic gonadotropin, autoimmune thyroiditis, Hashimoto disease, swelling in the neck, Graves disease, Hashimoto thyroiditis

Riedel struma, toxic multinodular goiter, subacute thyroiditis, diffuse toxic goiter, toxic adenoma, Plummer disease, chronic lymphocytic thyroiditis, sporadic goiter, congenital goiter, physiologic goiter, Pemberton maneuver, postpartum thyroiditis, Wolff-Chaikoff effect, lithium ingestion, pituitary thyroid hormone resistance, thyroid-stimulating immunoglobulins, thyroid hormone resistance, de Quervain thyroiditis, silent thyroiditis, Riedel thyroiditis, granulomatous disease, thyroid malignancy

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Contributor Information and Disclosures

Author

James R Mulinda, MD, FACP, FACE, Consulting Staff, Department of Endocrinology, Endocrinology Associates, Inc
James R Mulinda, MD, FACP, FACE is a member of the following medical societies: American College of Clinical Endocrinologists and American College of Physicians
Disclosure: Nothing to disclose.

Medical Editor

Steven R Gambert, MD, MACP, Chairman, Department of Medicine, Physician-in-Chief, Sinai Hospital of Baltimore; Professor of Medicine, Program Director, Internal Medicine Program, Johns Hopkins University School of Medicine
Steven R Gambert, MD, MACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American Geriatrics Society, Association of Professors of Medicine, Endocrine Society, and Gerontological Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kent Wehmeier, MD, Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine
Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, and International Society for Clinical Densitometry
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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