Toxic Nodular Goiter is a relatively common cause of hyperthyroidism. A goiter simply means an enlarged thyroid gland. A nodule is a growth within the thyroid gland, which is often benign. Rarely, it can be malignant.
What is Toxic Nodular Goiter
In the case of a Toxic Nodular Goiter, often there are multiple nodules, which are hyper-functioning, giving rise to hyperthyroidism. Toxic simply means that the goiter is giving rise to hyperthyroidism. Rarely, there may be a single hyper-functioning nodule.
Patients with Graves’ disease usually have a goiter as well, but this goiter is typically diffuse. That’s why it is called Toxic Diffuse Goiter, which is another name for Graves’ disease.
In case of a Toxic Nodular Goiter, usually a person has a visible goiter for a number of years with normal thyroid function. Then, hyperthyroidism develops very slowly. This is in sharp contrast to Graves’ disease, where hyperthyroidism develops rapidly and the goiter is diffuse, not nodular. However, rarely a nodule may be present in the thyroid gland of a Graves’ disease patient. It may carry a higher than normal risk of malignancy, and therefore, an ultrasound-guided Fine Needle Aspiration (FNA) biopsy should be considered in a Graves’ disease patient with a thyroid nodule.
Symptoms of Toxic Nodular Goiter
Symptoms of hyperthyroidism in a toxic nodular goiter are usually minimal. In the elderly, the only symptoms may be new onset atrial fibrillation or congestive heart failure. Rarely, a multi-nodular goiter may cause some pressure symptoms, such as compression on the trachea, difficulty swallowing or hoarseness of voice.
Diagnosis of Toxic Nodular Goiter
Diagnosis is based on the clinical findings of a nodular goiter and a low TSH. Free T3 and Free T4 may be normal or elevated.
The next step is to do a Radioiodine uptake and scan to confirm the hyper-functioning status of these nodules, which manifest as hot nodules on the scan. What is a hot nodule? When a nodule takes up more radioiodine than usual uptake by the rest of the gland, it is called a hot nodule. Hot nodules are almost never malignant.
An Ultrasound of the thyroid should also be done to evaluate the size and other features of the nodules. Usually, a multi-nodular gland with hyperthyroidism is non-malignant. However, if there is a large nodule, or if a nodule starts to enlarge or has suspicious features on an ultrasound, an ultrasound-guided Fine Needle Aspiration (FNA) biopsy should be considered to exclude malignancy.
Treatment of Toxic Nodular Goiter
Treatment of Toxic nodular goiter is with surgery. Occasionally, radioactive iodine is employed in an elderly patient, whose overall health may be too poor to undergo surgery.
Excerpts from my book,”Graves’ Disease And Hyperthyroidism”
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