Toxic multinodular goiter surgery

Surgery is the mainstay of treatment for toxic multinodular goiter. Almost all multinodular goiters can be surgically removed through a collar incision. Usually, subtotal thyroidectomy is performed but unilateral thyroid lobectomy can also be performed in selected cases.

Surgery is the mainstay of treatment for toxic multinodular goiter.^{[1][2][3][4][5][6]}

Indications of surgery for multinodular goiter (MNG) includes:

• Rapid enlargement of goiter
• Rapidly enlarging thyroid nodules
• FNAC is positive or suspicious of malignancy
• Compression of trachea, esophagus, and other neck structures
• Substernal thyroid extension
• Co-existence of hyperparathyroidism
• Risk of malignancy
  • Suspicious cervical lymphadenopathy
  • Radiation exposure

Almost all multinodular goiters can be surgically removed through a collar incision. An additional thoracotomy is very rarely necessary.

• If surgery is chosen as treatment for TMNG or TA, patients with overt hyperthyroidism should be rendered euthyroid prior to the procedure with MMI pretreatment, with or without beta–adrenergic blockade. Preoperative iodine should not be used in this setting.^[1]

Benefits of total thyroidectomy include:^[7]

• Adequate removal of the diseased gland
• Prevention of recurrence
• Avoidance of completion surgery in case of malignancy

Bilateral subtotal thyroidectomy includes total lobectomy on the dominant lobe and subtotal lobectomy on the contralateral lobe. Bilateral subtotal thyroidectomy is effective in the treatment of multinodular goiter (with hot or cold nodules).^[7]
Benefits of Subtotal thyroidectomy:

• Comparable to total thyroidectomy
• Low incidence of hypoparathyroidism

A unilateral thyroid lobectomy may be performed if only one thyroid lobe is enlarged.

The side effects associated with thyroidectomy include:^[8][9][10]

• Post-operative hypothyroidism
• Recurrent laryngeal palsy
• Hypocalcaemia secondary to hypoparathyroidism

The indications of radioactive iodine therapy includes:

• Advanced patient age
• Significant comorbidity
• Prior surgery or scarring in the anterior neck
• Small goiter size

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