Editing Goitre (section)

== '''Management options''' ==

* Surveillance
* TSH suppression with thyroid     hormone supplementation
* RAI ablation
* Thyroidectomy


'''Advantages and disadvantages of the treatment options in nontoxic multinodular goiter'''
{| class="wikitable"
| 
|'''Advantages'''
|'''Disadvantages'''
|-
|'''Surgery'''
|Significant goiter  reduction

Rapid  decompression of trachea

Prompt relief of  symptoms

Definite  histologic diagnosis
|Inpatient

High cost

Surgical risk

Vocal cord  paralysis: approximately 1%

Hypoparathyroidism:  approximately 1%

Risk of  hypothyroidism dependent of resection

Risk of recurrence  dependent of resection
|-
|'''Radioiodine'''
|Most often  outpatient

If outpatient: low  cost

Few subjective  side effects

Goiter reduction:  50% within one year

Improves  inspiratory capacity in long term

Can be repeated  successfully
|Limitation of  administrated radioactivity

Restricted  proximity to other persons

Contraceptives  needed in fertile women

Gradual reduction  of the goiter

Decreasing effect  with increasing size

Small risk of  acute goiter enlargement

Risk of  thyroiditis: 3%

Risk of transition  into Graves' disease: 5%

One-year risk of  hypothyroidism: 15 to 20%

Long-term cancer  risk unknown
|-
|'''Levothyroxine'''
|Outpatient

Low cost

May prevent new  nodule formation
|Low efficacy

Lifelong treatment

Adverse effects  (bone, heart)

Not feasible when  TSH is suppressed
|}


Observation

* Good for patients with     asymptomatic smaller goitres (<80mL)
* Start off with yearly TSH and     USS


TSH suppression

* Goitre size reductions in     about 30% of patients
* Balance ease of intervention     with risks of lifelong subclinical hyperthyroidism on heart and bones


Radio-iodine ablation (RAI)

* Can reduce goitre size by up     to 50% over a 1-year period
* Gradual effect
* Acute transient thyroiditis     can occur (3%), exacerbating local symptoms
* Ineffective for larger     goitres


Surgery

* Indications
** Absolute
*** Obstructive symptoms       without other cause
*** Tracheal compression
*** Suspected or proven       malignancy as per Bethesda, where appropriate surveillance would be       hampered
*** Substernal extension
*** Patient preference       (assuming they are an appropriate candidate)
* Extent of surgery
** Tailor to patient - whether      to take both lobes or just one
** Prefer total thyroidectomy      in patients with evidence of bilateral goitre, positive family history      thyroid disease, patients on thyroid hormone supplementation
** Subtotal thyroidectomy      associated with up 50% recurrence
** Subtotal may be favoured in      patients that will struggle to take medication
* Pre-op assessment
** TSH
** CT/MRI
*** Likely to be resectable       through standard cervical incision if the goitre extends inferiorly only       as far as the superior aspect of the aortic arch
*** Those extending further,       extending posteriorly, and/or crossing the midline from the dominant       side are significantly more difficult and likely to require sternal       split and partial or even total median sternotomy
** Flow-volume loop if ?upper      airway obstruction
** ?FNA if malignancy suspected
** Fibre-optic intubation may      be necessary if marked tracheal deviation