Nontoxic goiter is thyroid enlargement unrelated to hypothyroidism, hyperthyroidism, inflammation or neoplasia.
Etiology is usually unknown. Some known causes include iodine deficiency, iodine excess, goitrogen ingestion, autoimmune disorders, thyroid hormone production defects and certain medications.
It is usually asymptomatic.
Symptomatic patient may present with painless neck swelling, cosmetic complaints, shortness of breath, sudden increase in goiter size with pain due to hemorrhage, larger goiter causing obstructive signs eg dysphagia, choking sensation and Pemberton's sign.


  • Diagnosis of exclusion to rule out goiter due to hypothyroidism, hyperthyroidism, autoimmune thyroiditis, invasive fibrous thyroiditis, medications & iodine deficiency or excess


  • Cosmetic complaints (disfigurement due to enlarged goiter), obstructive complaints, growth rate & family history

Physical Examination

  • Inspect neck (check size, nodules & texture of goiter), detect obstructive signs (stridor, Pemberton’s sign, plethora, etc)
    • Nontoxic multinodular goiter: Multiple, distorted nodules of varying sizes
    • Diffuse nontoxic goiter: Symmetrical, enlarged, non-tender, soft gland w/o nodules 
  • A retrosternal goiter may not be evident on physical exam

Laboratory Tests

Thyroid Function Tests

  • Measure serum thyroid stimulating hormone (TSH) & free thyroxine (FT4) levels [measure serum free triiodothyronine (FT3) levels if FT4 is normal & in nodular goiter] to exclude hyperthyroidism & hypothyroidism
    • Euthyroid state (normalized serum FT3 & FT4 levels) may suggest diagnosis of goiter (simple/nontoxic)
    • TSH suppression may develop due to increasing goiter size
    • FT3 toxicosis may occur in multinodular goiter
  • Measure: Thyroid peroxidase (TPO) antibodies, thyroglobulin antibodies & TSH receptors antibodies to exclude autoimmune thyroid diseases

Fine Needle Aspiration Cytology (FNAC)

  • Performed to rule out malignancy in cases of suspicious nodules
  • May be performed guided w/ ultrasound in cases of nonpalpable nodules w/ diameter of ≥1 cm

Pulmonary Function Tests

  • Performed to determine the degree of airway obstruction


Thyroid Ultrasound

  • Measures thyroid size, identifies the structure & evaluates diffuse changes in the thyroid gland
  • Provides a measure of goiter growth rate over time & posttreatment
  • Determines extent of nodularity

Thyroid Scintigraphy

  • Visualizes goiter, determines its inherent properties; identifies hot & cold nodules

X-ray of the Neck & Upper Mediastinum

  • Used to determine the presence of tracheal compression

Computed Tomography (CT)/Magnetic Resonance Imaging (MRI)

  • Perform CT/MRI (to evaluate the anatomy of the goiter & the extent of substernal extension), if substernal goiters are suspected
  • Pemberton’s sign, obstructive signs & symptoms suggest substernal goiter
  • Substernal goiter may obstruct thoracic inlet & compress trachea


  • Potential complications: Recurrent laryngeal nerve palsy (1-2%), hypothyroidism (5-8%) & hypoparathyroidism (2-4%)
  • May administer low dose of T4 after surgery to suppress regrowth of goiter if serum TSH is elevated
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Endocrinology - Malaysia digital copy today!
Editor's Recommendations
Most Read Articles
01 Jun 2015
Long-term oral testosterone undecanoate significantly improved IPSS quality of life scores in a 1-year, randomised, multicentre, double-blind trial among aging hypogonadal men.
Rachel Soon, 01 Jun 2016

The inclusion of statins in managing chronic kidney disease (CKD) may help reduce patient mortality from stroke and possibly other cardiovascular events, according to an expert at the 7th Malaysian Endocrine and Metabolic Society (MEMS) Annual Congress.

Rachel Soon, 01 Jun 2016

Patients with hypercholesterolaemia with unchanging LDL-cholesterol levels after 6 weeks of statin treatment should be actively assessed for either statin intolerance or resistance, says an expert at the 7th Malaysian Endocrine and Metabolic Society (MEMS) Annual Congress.

Prof. Cyrus Rustam Kumana, 07 Jul 2016

This case scenario was presented at a grand round in the Department of Medicine, The University of Hong Kong. Unlike traditional grand rounds that directly or indirectly deal with clinical challenges posed by patients, this one was equally about doctors and how they care for their charges. All doctors who tend patients dread being implicated on the receiving end of medico-legal proceedings. This topic is therefore intimately linked to the professionalism of doctors, their standing in the community, and the ethical aspects of how they interact with patients and relatives.