Treatment Guideline Chart

Nontoxic diffuse 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.

Goiter%20nontoxic%20(simple)--%20diffuse%20-and-%20multinodular Diagnosis


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


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

Physical Examination

  • Inspect neck (check size, nodules and 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 without nodules 
  • A retrosternal goiter may not be evident on physical exam

Laboratory Tests

Thyroid Function Tests

  • Measure serum thyroid stimulating hormone (TSH) and free thyroxine (FT4) levels [measure serum free triiodothyronine (FT3) levels if FT4 is normal and in nodular goiter] to exclude hyperthyroidism and hypothyroidism
    • Euthyroid state (normal serum FT3 and 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 and TSH receptors antibodies to exclude autoimmune thyroid diseases

Fine Needle Aspiration Cytology (FNAC)

  • Performed to rule out malignancy in cases of suspicious nodules
  • Indicated if the patient has a history of rapid growth, pain, or tenderness, also if there is unusual firmness in one region of the goiter; or sonographically detected nodules with indeterminate or suspicious sonographic features
  • May be performed with ultrasound guidance in cases of nonpalpable nodules with diameter of ≥1 cm

Pulmonary Function Tests

  • Performed to determine the degree of airway obstruction


Thyroid Ultrasound

  • Preferred and most useful imaging modality to guide disease management and treatment of nodular goiter
  • Gold standard for measuring thyroid size, identifying the structure and evaluating diffuse changes in the thyroid gland
  • Recommended in patients with physical examination revealing thyroid asymmetry, focal firm consistency or tenderness, rapid growth of goiter, and goiter with normal TSH level and negative TPO antibodies
  • Provides a measure of goiter growth rate over time and posttreatment
  • Determines extent of nodularity

Thyroid Scintigraphy

  • Visualizes goiter, determines its inherent properties; identifies hot and cold nodules
  • Recommended in patients with solitary thyroid nodule or multinodular goiter with low TSH levels

X-ray of the Neck and 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 and the extent of substernal extension), if substernal goiters are suspected
    • Pemberton’s sign, obstructive signs and symptoms suggest substernal goiter
    • Substernal goiter may obstruct thoracic inlet and compress trachea
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