Further Outpatient Care
The patient with a large goiter and no obstructive symptoms can be monitored in an outpatient setting. Conduct a physical examination every 6 months to determine if obstructive symptoms have developed or worsened and to perform thyroid function tests (ie, TSH, free T4).
Depending on iodine intake in the diet, some of these patients develop thyroid autonomy and thyrotoxicosis.
Often, thyroid imaging is not necessary when the patient is examined by an endocrinologist experienced in thyroid examinations. The method of choice is ultrasonography unless the goiter extends into the thoracic inlet.
Routine nuclear scintigraphy is not necessary.
Transfer
Transfer may be required in patients with significant tracheomalacia who require surgery. Long-term compression of the trachea by a nontoxic goiter causes tracheal cartilage to lose its strength. This can be life threatening, and tracheal intubation or tracheotomy may be required.
Additionally, if a goiter extends significantly into the thorax, a thoracic surgeon may be needed to open the chest wall to fully excise the goiter.
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Intrathoracic goiter causing obstruction. This patient has a visible goiter on physical examination. In addition, he has distension of his left external jugular vein, facial erythema (when compared with his shoulder), and cutaneous varicosities of venous blood draining from his head into his chest because of jugular obstruction from his goiter.
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Technetium-99m (99mTc) thyroid scan of a large, nontoxic multinodular goiter. Multiple cold and hot nodules are observed in the enlarged thyroid gland. The white arrow indicates sternal notch marker.
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Areas of autonomy with excess thyroid hormone secretion in a large nodular goiter. This technetium-99m (99mTc) thyroid scan shows hot and cold nodules in a multinodular goiter. Although the patient's thyroid-stimulating hormone level had become progressively suppressed, it was within the reference range, at 0.4 mU/mL (reference range 0.35-5.5 mU/mL).
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Nontoxic goiter of the thyroid gland with tracheal compression. An axial, noncontrast computed tomography scan through the thyroid shows significant tracheal compression.
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Relief of tracheal compression after subtotal thyroidectomy of large, obstructive, nontoxic multinodular goiter. (A) Laryngoscopy demonstrating critical tracheal narrowing before thyroidectomy; (B) laryngoscopy showing widened patent trachea after thyroidectomy.
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Multinodular goiter. On visual inspection of the neck (image on left), this patient appears to have a goiter. The computed tomography scan (image on right) shows the asymmetrical goiter, measuring 9.3 x 7.4 cm, with tracheal deviation, although no tracheal obstruction is present.
