goiter%20nontoxic%20(simple)--%20diffuse%20-and-%20multinodular
GOITER NONTOXIC (SIMPLE): DIFFUSE & MULTINODULAR
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.

Pharmacotherapy

Levothyroxine (T4)

  • May be an alternative to surgery & radioactive iodine therapy
  • More suitable for patients w/o thyroid-stimulating hormone (TSH) suppression or w/ high serum TSH levels
  • Has been used to prevent recurrences after surgery
  • Actions: Suppresses TSH production causing goiter shrinkage
  • Effects based on clinical studies in the management of nontoxic goiter:
    • Goiter size decreases by 25% in 9 months in 51% of patients
  • Not recommended for treatment of nontoxic multinodular goiter due to its low efficacy & risk of thyrotoxicosis
  • Prolonged treatment w/ T4 is required to maintain goiter size reduction & prevent recurrences
    • Prolonged TSH suppression by T4 may also increase risk of bone loss & atrial fibrillation

Radioactive Iodine

  • As an alternative to surgery (especially in elderly, patients unfit for surgery or w/ TSH suppression)
  • Effects based on clinical study in the management of nontoxic goiter:
    • Goiter size decreases by 45% in 2 years in 97% of patients (the greatest reduction in goiter size during the 1st years)
    • Recurrence rate: 8% after 3-5 years
    • Reduces obstructive signs & symptoms (eg tracheal lumen widened by up to 36%; improvement in stridor & dyspnea)
    • Normalize serum TSH w/o causing hypothyroidism
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