eMedicine Specialties > Endocrinology > Thyroid

Goiter, Nontoxic: Treatment & Medication

Author: Stephanie L Lee, MD, PhD, Fellow, Association of Clinical Endocrinology; Director of Thyroid Nodule and Cancer Center, Associate Chief, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center; Associate Professor, Department of Medicine, Boston University School of Medicine
Coauthor(s): Sonia Ananthakrishnan, MD, Attending Physician, Department of Medicine, Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine/Boston Medical Center
Contributor Information and Disclosures

Updated: May 5, 2009

Treatment

Medical Care

Nontoxic goiters usually grow very slowly over decades without causing symptoms. Without evidence of rapid growth, obstructive symptoms (eg, dysphagia, stridor, cough, shortness of breath), or thyrotoxicosis, no treatment is necessary. Therapy is considered if growth of the entire goiter or a specific nodule is present, especially if intrathoracic extension of the goiter, compressive symptoms, or thyrotoxicosis exists. The intrathoracic extension of the goiter cannot be assessed by palpation or biopsy. The goiter, if significant in size, should be removed surgically.² The currently available therapies include thyroidectomy, radioactive iodine therapy, and levothyroxine (L-thyroxine, or T4) therapy.

• Radioactive iodine therapy - Radioiodine therapy of nontoxic goiters is often performed in Europe. It is a reasonable therapeutic option, particularly in patients who are older or have a contraindication to surgery.^3,4
  • Radioactive iodine therapy for nontoxic goiters was reintroduced in the 1990s. Careful studies have shown a reduction in thyroid volume in nearly all patients after a single dose of therapy.
  • Of patients with nontoxic diffuse goiter, 90% have an average of 50-60% reduction in goiter volume after 12-18 months, with a reduction in compressive symptoms. The decrease in goiter size has positively correlated with the dose of iodine-131 (¹³¹ I). Reduction in goiter size is greater in younger patients and in individuals who have only a short history of goiter or who have a small goiter. Baseline TSH is not a predictor of response to radioactive iodine.
  • Obstructive symptoms improved in most patients who received radioactive iodine.
  • Adverse effects, including thyroiditis, occurred, but no patient reported worsening of compressive symptoms requiring treatment. No long-term follow-up reports on patients treated with radioactive iodine exist. Patients should always be monitored clinically after¹³¹ I therapy, for evidence of goiter regrowth.
    • Transient hyperthyroidism is rare and typically occurs in the first 2 weeks after treatment.
    • Unlike patients with hyperthyroidism who are treated with radioactive iodine, only a small percentage of patients with nontoxic goiter develop hypothyroidism after radioactive iodine treatment
  • Recombinant human TSH (rhTSH)^5,6,7 may have a role in radioactive iodine treatment for nontoxic goiter. Pretreatment with rhTSH 24 hours prior to therapy can reduce the amount of radioiodine needed to shrink the goiter (up to a 50% reduction).
• Thyroid hormone suppressive therapy - The use of T4 in a euthyroid individual to shrink a nontoxic goiter is controversial.
  • One study showed that T4 therapy for nontoxic goiter reduced thyroid volume in 58% of patients, compared with 4% of patients treated with a placebo. However, these results have not yet proven to be reproducible, and the benefit of using T4 needs to be weighed against the risk of the resultant subclinical hyperthyroidism associated with an increased risk of decreased bone mineral density and increased atrial fibrillation.
  • Goiter growth typically resumes after cessation of T4 therapy.

Surgical Care

Thyroidectomy or surgical decompression causes rapid relief for obstructive symptoms (see image below and Image 4).²

• Most intrathoracic goiters may be removed from a cervical incision without sternotomy. Performing bilateral subtotal thyroidectomy has been recommended to reduce the risk of continued goiter growth. The rate of goiter recurrence depends on the extent of surgery but should not be higher than 10% in 10 years.
• After bilateral subtotal thyroidectomy, all patients require thyroid hormone replacement therapy. The full replacement therapy should start immediately after surgery, with TSH levels checked 3-4 weeks postoperatively. Adjust thyroid hormone therapy, such as T4, to maintain a TSH level in the reference range. Some evidence exists that thyroid hormone replacement therapy prevents recurrence of nontoxic goiter after surgical removal.⁸
• The use of total thyroidectomy to treat benign multinodular goiter has met with some concern, owing to the risk of parathyroid function damage and laryngeal nerve injury posed by the procedure. Nonetheless, total thyroidectomy is also seen as a means of avoiding the pitfalls of subtotal thyroidectomy, specifically, the recurrence of goiter and the inadequate treatment of thyroid cancers, which can occur in apparently benign goiters. Results from a 2008 literature review indicated that the rate of permanent complications is the same for subtotal and total thyroidectomy; consequently, the report's authors concluded that total thyroidectomy should be the procedure of choice for the surgical treatment of benign multinodular goiters.²
• Results from a Swiss study of 72 patients indicated that a single dose of steroid prior to thyroidectomy for benign disease can, within 48 hours postsurgery, significantly reduce pain, nausea, vomiting, and voice alteration related to the procedure.⁹

Consultations

• Consult an endocrinologist in the complicated nontoxic goiter with nodule formation or obstructive symptoms.
• If a high index of suspicion for malignancy exists in a patient with hoarseness, lymphadenopathy, and previous radiation exposure as a child, consult a thyroid surgeon.

Diet

Diets low in iodine need supplementation, especially in developing countries where government-supported iodine supplementation is not available. Patients taking iodine supplements may need a reduction to avoid iodine-induced thyroid disease in predisposed individuals.

Medication

No specific treatment for nontoxic goiter exists. Childhood or adult goiter that is established because of iodine deficiency does not shrink after supplementation with iodine. Goiters due to a defect in thyroid hormone synthesis, dyshormonogenesis, are often reduced in size by thyroid hormone therapy. Attempting to shrink nontoxic goiters with T4 has been standard practice, but this therapy has generally fallen out of favor because of the risks of hyperthyroidism, with its detrimental effects on bone and cardiac function.

Thyroid hormones (L-thyroxine)

T4 has been used to reduce the size or suppress the further growth of goiters.

Levothyroxine (Synthroid, Levoxyl, Unithroid, Levothroid)

Minimal excess doses of T4 suppress thyrotropin (TSH) secretion from the pituitary. TSH is the primary stimulator of thyroid gland growth and thyroid hormone synthesis. For many years, the standard therapy of nontoxic goiter has been suppression of thyroid function by exogenous T4 therapy. This practice has been largely abandoned because of data showing cortical bone loss with chronic excess of thyroid hormone therapy and lack of benefit in suppressing growth of large nodular goiters. Studies have shown that T4 therapy is most effective in decreasing the size of small diffuse goiters in patients with a basal TSH within the reference range.

Antithyroid agents

Reduce goiter size.

Sodium iodide, or¹³¹ I (Iodotope)

Ultrasonographic studies have shown a decrease in thyroid volume after¹³¹ I therapy in the majority of patients with nontoxic goiter. When administered at a dose of 100 µCi per g of goiter (corrected for percent uptake of¹³¹ I at 24 h), thyroid volume decreases an average of 50-60% in 12-18 mo. In most patients, radioactive iodine therapy reduces compressive symptoms. Commonly used in Europe and Latin America but is not standard therapy in the United States unless the patient has contraindication for surgery. Theoretical concerns of radiation-induced swelling and worsening of compressive symptoms have not been supported in European studies. Often, low-iodine diets are recommended for 5 d up to several wk before therapy.

• Search for CME/CE on This Topic »

• Goiter, Toxic Nodular (Endocrinology)
• Goiter (Endocrinology)
• Hyperthyroidism (Endocrinology)
• Goiter, Lithium-Induced (Endocrinology)

• Thyroid Problems Treatment
• Thyroid Problems Symptoms
• Endocrine System Center
• Thyroid Problems Overview
• Thyroid Problems Causes

• TSH Pre-Treatment Improves Goiter Reduction by Radioiodine: Study
• AANS 2009: Novel Delivery for Topotecan Shows Promise for Gliomas
• Levothyroxine Suppression Increases Coagulation

• A Germline Mutation (A339V) in Thyroid Transcription Factor-1 (TITF-1/NKX2.1) in Patients With Multinodular Goiter and Papillary Thyroid Carcinoma
• Assessment of the Neck and Lymph Nodes in the Elderly Patient
• Putting Ethics on the Spot in Neurology

• Hypothyroidism Resource Center