Goiter Follow-up

Preoperatively, 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 includes hemodynamic monitoring, which is important in patients with preoperative hyperthyroidism or hypothyroidism.

Postoperative management also includes monitoring of serum calcium.

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

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.

Goiter prevention is based on etiology.

Correct iodine deficiency^[1] 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.

• 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.

• 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.

• 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.