Medication Summary
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 in children. T4 is less effective in shrinking dyshormonogenesis goiter in adults once hyperplastic nodules have developed. Attempting to shrink sporadic or nontoxic goiters with T4 used to be standard practice, but this therapy has fallen out of favor because of the risks of hyperthyroidism, with its detrimental effects on bone and cardiac function, and lack of efficacy to shrink thyroid nodules and goiters.
Thyroid hormones (L-thyroxine)
Class Summary
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
Class Summary
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.
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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.
