Toxic Nodular Goiter Clinical Presentation

Updated: Oct 25, 2021
  • Author: Philip R Orlander, MD, FACP; Chief Editor: George T Griffing, MD  more...
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Presentation

History

Thyrotoxic symptoms

Most patients with toxic nodular goiter (TNG) present with symptoms typical of hyperthyroidism, including heat intolerance, palpitations, tremor, weight loss, hunger, and frequent bowel movements.

Elderly patients may have more atypical symptoms, including the following:

  • Weight loss is the most common complaint in elderly patients with hyperthyroidism.

  • Anorexia and constipation may occur, in contrast to frequent bowel movements often reported by younger patients.

  • Dyspnea or palpitations may be a common occurrence.

  • Tremor also occurs but can be confused with essential senile tremor.

  • Cardiovascular complications occur commonly in elderly patients, and a history of atrial fibrillation, congestive heart failure, or angina may be present.

F Lahey, MD, first described apathetic hyperthyroidism in 1931; this is characterized by blunted affect, lack of hyperkinetic motor activity, and slowed mentation in a patient who is thyrotoxic.

Obstructive symptoms

A significantly enlarged goiter can cause symptoms related to mechanical obstruction.

A large substernal goiter may cause dysphagia, dyspnea, or frank stridor. Rarely, this goiter results in a surgical emergency.

Involvement of the recurrent or superior laryngeal nerve may result in complaints of hoarseness or voice change.

Asymptomatic or minimal symptoms

Many patients are asymptomatic or have minimal symptoms and are incidentally found to have hyperthyroidism during routine screening. The most common laboratory finding is a suppressed TSH with normal free thyroxine (T4) levels.

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Physical Examination

Findings of hyperthyroidism may be more subtle than those of Graves disease. Features may include widened, palpebral fissures; tachycardia; hyperkinesis; moist, smooth skin; tremor; proximal muscle weakness; and brisk deep tendon reflexes.

The size of the thyroid gland is variable. Large substernal glands may not be appreciable upon physical examination.

A dominant nodule or multiple irregular, variably sized nodules are typically present. In a small gland, multinodularity may be apparent only on an ultrasonogram. Chronic Graves disease may present with some nodularity; therefore, establishing the diagnosis is sometimes difficult.

Hoarseness or tracheal deviation may be present upon examination.

Mechanical obstruction may result in superior vena cava syndrome, with engorgement of facial and neck veins (Pemberton sign). [6]

Stigmata of Graves disease (eg, orbitopathy, pretibial myxedema, acropachy) are not observed.

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