Treatment of multinodular goiter by surgery.

Abstract

Although this comment emphasizes surgical treatment of multinodular goiter, the Author affirms that he feels both surgery and radioactive iodide (RAI) therapy have a role in managing this common condition. Multinodular goiter is typically a slowly evolving process and most often presents for management in post-menopausal women. The reasons for seeking treatment range from adverse cosmetic appearance, to concern about malignancy or symptoms indicating partial obstruction of the esophagus, compression of the trachea, or venous return to the superior vena cava. Less commonly, hoarseness prompts attention. Occasionally episodes of pain and swelling may be present. Typically, benign, non-toxic multinodular goiters grow to considerable size before patients seek attention. It is unusual for the gland to be less than three times normal size (greater than 45-50 g) when symptoms arise. Diagnostic studies, in addition to FTI, TSH, and often antibodies, may include ultrasound for examination of nodules, sometimes isotope scanning, occasionally CAT scans or X-rays to evaluate tracheal compression, and FNA of dominant nodules. Problems that suggest need for a surgical approach include adenopathy, very large size, progressive growth of a nodule or concern about FNA cytology, hoarseness or continued pain, marked tracheal compression, or obstruction of venous return. Surgery is conventionally done without specific medical preparation, currently involves admission on the day of operation, and typically the patient is discharged the following day. Patients are usually back at full activity in 10-14 days. Surgery almost always offers a good cosmetic outcome, and provides a histologic diagnosis. A bilateral subtotal thyroidectomy is often done, attempting to remove nodular tissue but leaving the posterior capsule and “normal” tissue intact. This operation rarely causes recurrent nerve paralysis or hypoparathyroidism. There is a trend toward total thyroidectomy in some centers, in an attempt to avoid recurrences (1). Almost all goiters can be removed through a transcervical incision. When done by a capable surgeon, the incidence of hypoparathyroidism, after surgery for multinodular goiter, is approximately 1%, unilateral recurrent nerve damage is approximately 1%, bilateral recurrent nerve damage almost never occurs, and tracheostomy should almost never be a problem (2). The low incidence of side-effects described may not be representative of results in hospitals where surgeons infrequently perform this operation. Obviously permanent hypoparathyroidism is a major lifelong complication, but unilateral recurrent nerve damage is typically a minor problem. Patients may, or may not, be started on replacement T4 therapy after subtotal resection, since the residual tissue can usually recover enough to ensure euthyroidism. Administration of thyroid hor