AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

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Background

A nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function. Endemic goiter is defined as thyroid enlargement that occurs in more than 10% of a population, and sporadic goiter is a result of environmental or genetic factors that do not affect the general population.

Pathophysiology

The histopathology varies with etiology and age of the goiter. Initially, uniform follicular epithelial hyperplasia (diffuse goiter) is present with an increase in thyroid mass. As the disorder persists, the thyroid architecture loses uniformity, with the development of areas of involution and fibrosis interspersed with areas of focal hyperplasia. This process results in multiple nodules (multinodular goiter). On nuclear scintigraphy, some nodules are hot, with high isotope uptake (autonomous) or cold, with low isotope uptake, compared with the normal thyroid tissue (see Images 1-2). The development of nodules correlates with the development of functional autonomy and reduction in thyroid-stimulating hormone (TSH) levels. Clinically, the natural history of a nontoxic goiter is growth, nodule production, and functional autonomy resulting in thyrotoxicosis in a minority of patients.

Frequency

United States

Iodine comes from ingestion of food. Iodine content of the soil determines the iodine content of plants and animals. Iodine is washed from the soil by water and is eventually washed out to the oceans. In general, areas with mountain ranges or heavy rainfall and flooding are iodine deficient. Iodine deficiency occurs in populations that depend on locally grown food and rely on vegetable rather than animal or fish protein.

Studies have shown that iodine supplementation can eliminate cretinism and is highly effective in the prevention of endemic goiter. When urinary iodide falls below 25 micrograms per gram of creatinine, a palpable goiter occurs in 40-90% of the population, hypothyroidism occurs in 30-50% of the population, and cretinism occurs in 1-10% of the population. The seminal studies by David Marine, MD, in 1917 demonstrated the reduction in goiter of adolescent girls in Ohio from 20% to 5% by iodine supplementation.

Table salt has been supplemented in the United States since the 1920s for the prevention of cretinism and endemic goiter. The iodine intake in the United States, according to the latest National Health and Nutrition Examination Survey III (NHANES III), is adequate at 145 micrograms per milligram of creatinine. This adequate iodine intake in the United States eliminates the most common cause of endemic goiter in most populations.

Sporadic goiter is the most common cause of nontoxic goiter in the United States. The incidence of sporadic nontoxic goiter has been estimated in North America at approximately 5%. Sporadic goiter does not usually occur in people before puberty, and it does not have a peak incidence. Generally, the development of palpable thyroid nodules and goiter progressively increases with age. Prevalence of palpable nodules is approximately 5-6% in people aged 60 years, but, on autopsy and ultrasound imaging findings, the incidence of small nonpalpable nodules approaches 50% in people aged 60 years.

International

More than 2.2 billion people worldwide have some form of iodine deficiency disorder. Twenty-nine percent of the world’s population lives in a region that has iodine deficiency (primarily in Asia, Latin American, central Africa, and regions of Europe). Of those at risk, 655 million were known to have goiter. In the iodine-deficient regions of the world, goiter is more common than in the United States. The prevalence of goiter can be estimated based on the iodine intake of the population. 

As reported by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), the absence of iodine deficiency (ie, median urine iodine >100 mg/dL) is associated with a goiter prevalence of less than 5%, mild iodine deficiency (ie, median urine iodine 50-99 mg/dL) is associated with a goiter prevalence of 5-20%, moderate iodine deficiency (ie, median urine iodine 20-49 mg/dL) is associated with a goiter prevalence of 20-30%, and severe iodine deficiency (ie, median urine iodine 20-49 mg/dL) is associated with a goiter prevalence of greater than 30%.

Mortality/Morbidity

Endemic goiters associated with iodine deficiency are associated with sometimes immense thyroid hypertrophy, hypothyroidism, and cretinism (see Iodine Deficiency). Sporadic goiters are generally asymptomatic and found either by a clinician's physical examination or by the patient's observation of neck enlargement. Occasionally, the goiter may cause symptoms due to pressure on anterior neck structures, including the trachea (wheezing, cough, globus hystericus [anterior neck pressure]), the esophagus (dysphagia), and the recurrent laryngeal nerve (hoarseness).

Rarely, the obstruction can be dangerous because of narrowing of the trachea and the development of tracheitis with edema and tracheomalacia, leading to severe narrowing of the airway with serious obstruction resulting in a respiratory emergency (see Images 3-4).

Race

No convincing epidemiological studies suggest that race plays an important role in the development of nontoxic goiter. Generally, the lower socioeconomic conditions in nonindustrialized countries resulting in iodine deficiency have a more important role than race in the development of a goiter.

Sex

Diffuse and nodular goiter is more common in women than in men. According to the best estimate, 1.2-4.3 women have goiter for every man who has goiter.

Age

Sporadic goiter from dyshormonogenesis, a genetic error in proteins that are necessary for thyroid hormone synthesis, occurs during childhood. Endemic goiter due to iodine deficiency occurs during childhood and continues to increase in size with age. Other causes of sporadic goiter rarely occur before puberty and do not have a peak age of occurrence. Thyroid nodules increase in incidence with age.

CLINICAL

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History

The thyroid gland usually grows outward because of its location anterior to the trachea (see Image 5). Occasionally, the thyroid wraps around and compresses the trachea and/or the esophagus or extends inferiorly into the anterior mediastinum (see Image 3).

• Growth pattern
  
  
  • Determining whether the goiter has been present for many years and whether a change has occurred in the recent past is important.
  
  
  
  • Recent or accelerated growth of a discrete nodule or thyroid lobe should raise the suspicion for malignancy.
  
  
  
  • Goiters are rarely painful or grow quickly unless recent hemorrhage into a nodule has occurred.
     
• Obstructive symptoms
  
  
  • Tracheal compression is generally asymptomatic until critical narrowing has occurred (see Image 3).
  
  
  
  • Patients develop dyspnea and stridor, especially with exertion. In patients with intrathoracic goiter, the dyspnea and stridor may be nocturnal or positional (ie, occurring when the patient's arms are raised) when the thoracic outlet is narrowed.
  
  
  
  • Hemorrhage into a nodule or cyst or development of bronchitis may acutely worsen the respiratory symptoms in a patient with tracheal narrowing.
  
  
  
  • The esophagus is more posterior in the neck, and a goiter occasionally extends posteriorly and causes solid food and pill dysphagia.
  
  
  
  • Compression of the recurrent laryngeal nerve with vocal cord dysfunction may cause hoarseness. The superior laryngeal nerve controls the pitch of the voice. An expanding goiter may cause a change in the character of the voice, especially in individuals who use their voice extensively (eg, in certain occupations).
  
  
  
  • Compression of the venous outflow through the thoracic inlet by a mediastinal goiter results in facial plethora and dilated neck and upper thoracic veins (see Image 6). 
     
• Iodine intake: Obtain a careful diet history for iodine deficiency, iodine excess from medications (eg, amiodarone), health food store supplements, or seaweed.



• History of radiation: Record any history of head and neck radiation exposure, especially during childhood, which significantly increases the risk of thyroid malignancy as well as other thyroid abnormalities.



• Family history: Family history is very important in the evaluation of the patient with goiter. Investigate inherited forms of dyshormonogenesis in the pediatric patient, as well as familial papillary carcinoma of the thyroid and familial forms of medullary thyroid cancer (multiple endocrine neoplasia and familial medullary carcinoma of the thyroid).

Physical

Pertinent physical findings are limited to the evaluation of the shape, asymmetry, size, and consistency of nontoxic goiters; lymphadenopathy; and assessment of thyroid function.

• The thyroid evaluation starts with inspection of the neck for thyroid enlargement. Often, the thyroid enlargement can be detected only when the patient swallows.
  
  
  • The thyroid isthmus is usually located at or just below the level of the cricoid cartilage of the trachea. The lobes of the thyroid extend laterally and, if enlarged, may extend posterior to the sternocleidomastoid muscles. Up to 80% of thyroid glands may have a pyramidal lobe extending superiorly from the isthmus.
  
  
  
  • Assess the gland for overall size; in the United States, the normal weight is 15-20 g.
  
  
  
  • Assess the thyroid for asymmetry and determine whether a dominant nodule is present in an overall nodular goiter or a solitary nodule is present in an otherwise normal gland. Evaluate dominant nodules that are bigger than 1-1.5 cm or a solitary nodule of the same size by a thin-needle aspiration biopsy. Diffuse or nodular goiters without a dominant nodule do not require a biopsy for evaluation. 
     
• Obstruction
  
  
  • Examine patients with dyspnea and cough, especially with exertion, for tracheal obstruction. Note any tracheal deviation from midline.
  
  
  
  • The patient's voice is assessed for hoarseness.
  
  
  
  • Venous outflow obstruction of the head and neck can be elicited by the Pemberton maneuver by raising the patient’s arms above the head until they touch the sides of the head for 1 minute. A positive finding occurs with facial plethora or engorgement of the neck veins. 
     
• Physical assessment of thyroid dysfunction
  
  
  • Examine patients for signs of thyroid dysfunction.
  
  
  
  • Hypothyroidism is indicated by a sallow complexion, dysarthric speech, mental slowing, weight gain without change in appetite, cold intolerance, constipation, hypersomnia, and delayed relaxation of deep tendon reflexes.
  
  
  
  • Hyperthyroidism is indicated by tachycardia, atrial arrhythmia (eg, atrial fibrillation), diaphoresis, weight loss without change in appetite, heat intolerance, hyperdefecation, palmar erythema, lid lag, tremor, and brisk reflexes.
     
• Lymphadenopathy: Carefully examine the neck to identify any lymphadenopathy.

Causes

The most common worldwide cause of endemic nontoxic goiter is iodine deficiency. However, in patients with sporadic goiter, the cause is usually unknown. Nontoxic goiters have many etiologies, including the following:

• Iodine deficiency: Goiter formation occurs with moderately deficient iodine intake of less than 50 mcg/d. Severe iodine deficiency associated with intake of less than 25 mcg/d is associated with hypothyroidism and cretinism.
• Iodine excess: Goiter formation due to iodine excess is rare and usually occurs in the setting of preexisting autoimmune thyroid disease.
• Goitrogens
• • Drugs - Propylthiouracil, lithium, phenylbutazone, aminoglutethimide, iodine-containing expectorants

  • Environmental agents - Phenolic and phthalate ester derivatives and resorcinol found downstream of coal and shale mines

  • Foods - Vegetables of the genus Brassica (eg, cabbage, turnips, brussels sprouts, rutabagas), seaweed, millet, cassava, and goitrin in grass and weeds

• Dyshormonogenesis: A defect in the thyroid hormone biosynthetic pathway is inherited.
• Childhood head and neck radiation: Radiation exposure during childhood results in benign and malignant nodules.

DIFFERENTIALS

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Other Problems to be Considered

Hypothyroid goiter
Hyperthyroid goiter
Thyroid cysts
Developmental cervical cysts
Thyroid agenesis
Thyroglossal duct cyst
Nodular hyperplasia
Malignancy metastatic to the thyroid

WORKUP

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Lab Studies

• Assess all patients with goiter for thyroid dysfunction with a serum thyrotropin (TSH) assay. Second-generation or better TSH assays can detect clinically inapparent (subclinical) hyperthyroidism and hypothyroidism.
• • If the TSH is high, consider chronic autoimmune thyroiditis (Hashimoto thyroiditis) or ingestion of a goitrogen, such as lithium or amiodarone, as well as dyshormonogenesis in a child. Correction of the hypothyroid status by withdrawal of the goitrogen or institution of thyroid hormone replacement therapy may greatly reduce the size of the goiter.
  
  
  
  • If the TSH is low, measurement of serum free thyroxine (free T4) or free T4 index and total triiodothyronine (T3) is used to confirm the diagnosis of thyrotoxicosis. After many years, a nontoxic goiter may develop areas of functional autonomy and thyrotoxicosis (see Image 2). Treatment of thyrotoxicosis includes stabilization of the hyperthyroid state with antithyroid medications then surgical removal of the goiter or radioactive iodine ablative therapy.

Imaging Studies

• Assessment of size and extent of the goiter is necessary to determine if progressive growth of the thyroid is occurring. Clinical assessment by an experienced clinician is often accurate until the thyroid increases to 4-5 times the normal size.
• • Measurement of neck circumference is a crude measure of thyroid size. Ultrasonography is good for estimating numbers and the size of nodules but is inaccurate in the clinical setting for measuring the volume of large goiters. CT scan and MRI are expensive but excellent for assessing tracheal compression and intrathoracic extension of the goiter (see Image 1).
  
  
  
  • A barium swallow may be used to document esophageal obstruction in patients with significant symptoms of dysphagia.
  
  
  
  • Thyroid scintigraphy is not routinely indicated in the assessment of goiter size unless a concern of thyroid hemiagenesis exists. A nodule with equivocal findings on thin-needle aspiration may be further evaluated using thyroid scintigraphy. A hot area supports the presence of a benign lesion. Examples of technetium Tc 99m thyroid scan are shown in Image 1 and Image 2.

Other Tests

• Pulmonary function tests may be used as a functional assessment of tracheal compression. Characteristic changes of external tracheal compression can be detected in flow-volume loop tracings in asymptomatic patients with goiter. Direct laryngoscopy can also demonstrate tracheal compression (see Image 4).

Procedures

• A subset of patients presenting with goiter who do not have hyperthyroidism should have a fine-needle aspiration biopsy as the first diagnostic procedure. Clinical indication for biopsy includes asymmetric and/or rapid growth of a nodule or lobe of a thyroid gland. Generally, in patients with the usual nonnodular nontoxic goiter that is long-standing with slow growth, fine-needle biopsy is not necessary.

Histologic Findings

A variety of different features may be observed with fine-needle aspiration cytology of a multinodular goiter. This variation is mostly explained by different stages of nodule formation. A proliferative phase exists in which the sample may contain many follicular cells. This can sometimes be difficult to distinguish from a follicular adenoma versus a follicular carcinoma. Colloid is another prominent feature. It represents the stored thyroid hormone within the follicle. Its absence suggests a more worrisome diagnosis. After proliferation of follicular cells, a hemorrhage may occur inside the nodule. Erythrocytes and foamy macrophages that have ingested colloid material may be observed. Another potential area of concern is an aspiration that only returns cyst contents, ie, erythrocytes and macrophages without follicular cells. This cannot be used to definitively rule out the presence of thyroid cancer, and a reaspiration should be performed.

TREATMENT

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Medical Care

Nontoxic goiters usually grow very slowly over decades without causing symptoms. Without evidence of rapid growth, obstructive symptoms (eg, dysphagia, stridor, cough, shortness of breath), or thyrotoxicosis, no treatment is necessary. Therapy is considered if growth of the entire goiter or a specific nodule is present, especially if intrathoracic extension of the goiter, compressive symptoms, or thyrotoxicosis exists. The intrathoracic extension of the goiter cannot be assessed by palpation or biopsy. The goiter, if significant in size, should be removed surgically. The currently available therapies include thyroidectomy, radioactive iodine therapy, and levothyroxine (L-thyroxine or T4) therapy.

• Radioactive iodine therapy: Radioiodine therapy of nontoxic goiters is often performed in Europe. It is a reasonable therapeutic option, particularly in patients who are older or have a contraindication to surgery.
  
  
  • Radioactive iodine therapy for nontoxic goiters was reintroduced in the 1990s. Careful studies have shown a reduction in thyroid volume in nearly all patients after a single dose of therapy.
  
  
  
  • Of patients with nontoxic diffuse goiter, 90% have an average of 50-60% reduction in goiter volume after 12-18 months, with a reduction in compressive symptoms. The decrease in goiter size positively correlated with the dose of iodine I 131 (¹³¹I). Reduction in size of goiter is greater in younger patients, those with only a short history of goiter, and in those with a small goiter. Baseline TSH is not a predictor of response to radioactive iodine.
  
  
  
  • Obstructive symptoms improved in most patients who received radioactive iodine.
  
  
  
  • Adverse effects, including thyroiditis, occurred, but no patient reported worsening of compressive symptoms requiring treatment. No long-term follow-up of patients treated by radioactive iodine exists. Patients after ¹³¹I therapy should always be clinically monitored for evidence of goiter regrowth.
    
    
    • Transient hyperthyroidism is rare and typically occurs in the first 2 weeks after treatment.
    
    
    
    • Unlike with treating hyperthyroidism with radioactive iodine, only a small percentage of patients develop hypothyroidism after radioactive iodine for nontoxic goiter.
       
  • Recombinant human TSH (rhTSH) may have a role in treating nontoxic goiter with radioactive iodine. Pretreatment with rhTSH 24 hours prior to therapy can result in needing smaller doses of radioiodine to shrink the goiter (up to 50% reduction).
     
• Thyroid hormone suppressive therapy: The use of T4 in a euthyroid individual to shrink a nontoxic goiter is controversial.
  
  
  • One study showed that T4 therapy for nontoxic goiter reduced thyroid volume in 58% of patients compared with 4% reduction in patients treated with a placebo. However, these results have not been reproducible, and the benefit of using T4 needs to be weighed against the risk of the resultant subclinical hyperthyroidism that is associated with an increased risk of decreased bone mineral density and increased atrial fibrillation.
  
  
  
  • Goiter growth typically resumes after cessation of T4 therapy.

Surgical Care

Thyroidectomy or surgical decompression causes rapid relief for obstructive symptoms (see Image 3).

• Most intrathoracic goiters may be removed from a cervical incision without sternotomy. Performing bilateral subtotal thyroidectomy is recommended to reduce the risk of continued goiter growth. The rate of goiter recurrence depends on the extent of surgery but should not be higher than 10% in 10 years.



• After bilateral subtotal thyroidectomy, all patients require thyroid hormone replacement therapy. The full replacement therapy should start immediately after surgery, with TSH levels checked 3-4 weeks postoperatively. Adjust thyroid hormone therapy, such as T4, to maintain a TSH level in the reference range. Some evidence exists that thyroid hormone replacement therapy prevents recurrence of nontoxic goiter after surgical removal.

Consultations

• Consult an endocrinologist in the complicated nontoxic goiter with nodule formation or obstructive symptoms.
• If a high index of suspicion for malignancy exists in a patient with previous radiation exposure as a child, hoarseness, and lymphadenopathy, consult a thyroid surgeon.

Diet

Diets low in iodine need supplementation, especially in developing countries where government-supported iodine supplementation is not available. Patients taking iodine supplements may need a reduction to avoid iodine-induced thyroid disease in predisposed individuals.

MEDICATION

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No specific treatment for nontoxic goiter exists. Childhood or adult goiter that is established because of iodine deficiency does not shrink after supplementation with iodine. Goiters due to a defect in thyroid hormone synthesis, dyshormonogenesis, are often reduced in size by thyroid hormone therapy. Attempting to shrink nontoxic goiters with T4 has been standard practice, but this therapy has generally fallen out of favor because of the risks of hyperthyroidism with its detrimental effects on bone and cardiac function.

Drug Category: Thyroid hormones (L-thyroxine)

T4 has been used to reduce the size or suppress the further growth of goiters.

Drug Category: Antithyroid agents

Reduce goiter size.

FOLLOW-UP

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Further Outpatient Care

• The patient with a large goiter and no obstructive symptoms can be monitored in an outpatient setting. Conduct a physical examination every 6 months to determine if obstructive symptoms have developed or worsened and to perform thyroid function tests (ie, TSH, free T4).
• Depending on iodine intake in the diet, some of these patients develop thyroid autonomy and thyrotoxicosis.
• Often, thyroid imaging is not necessary when the patient is examined by an endocrinologist experienced in thyroid examinations. The method of choice is ultrasonography unless the goiter extends into the thoracic inlet.
• Routine nuclear scintigraphy is not necessary.

Transfer

• Transfer may be required in patients with significant tracheomalacia requiring surgery. The tracheal cartilage loses its strength because of long-term compression of the trachea by a nontoxic goiter. It can be life threatening, and tracheal intubation or tracheotomy may be required.
• Additionally, if a goiter extends significantly into the thorax, a thoracic surgeon may be needed to open the chest wall to fully excise the goiter.

Deterrence/Prevention

• Prevention of endemic goiter may be accomplished by iodine supplementation by using iodine supplements in drinking water sources or iodized oil on bread, which may be applied to a whole country.

Complications

• Complications of a nontoxic goiter occur because of growth and compression of neck structures or the development of areas of autonomy and thyrotoxicosis.

Prognosis

• Prognosis is good.
• Usually, nontoxic goiters grow very slowly over many years. Any rapid growth behavior must be evaluated for either degeneration or hemorrhage of a nodule or growth of a neoplasm.
• Often, in patients who present with progressive goiter growth, the patient with significant dysphagia or dyspnea must be evaluated for subtotal thyroidectomy.
• In some patients, radioactive iodine therapy could be considered, especially if the patient is older.

Patient Education

• Thyroid self-examination may be taught to patients to monitor their own bodies to detect early changes in gland size.
• For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems.

MISCELLANEOUS

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Medical/Legal Pitfalls

• Because of the difficulty in detecting nodules, close surveillance is necessary to ensure that no nodule is truly present. This may require ultrasound examination.



• Growth of a previously stable goiter or onset of clinical symptoms, such as development of a hoarse voice with vocal cord paralysis, should be evaluated expeditiously for malignant transformation.



• Remember the limitations of thyroid thin-needle aspiration in evaluating nodular thyroid disease. If the nodule is large, be concerned about sample bias. An adequate number of thyroid cells should be present for a full evaluation. A cyst represents a dilemma because often only inflammatory cells are observed. Additional procedures may be necessary to determine the true nature and rule out thyroid cancer.



• Antithyroid antibodies can be positive in as many as 10% of nontoxic goiters in the absence of thyroiditis.

MULTIMEDIA

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Media file 1:  Technetium Tc 99m thyroid scan of a large nontoxic multinodular goiter. Multiple cold and hot nodules are observed in the enlarged thyroid gland. The white arrow indicates sternal notch marker.
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Media type:  X-RAY

Media file 2:  Areas of autonomy with excess thyroid hormone secretion in a large nodular goiter. This technetium Tc 99m thyroid scan shows hot and cold nodules in a multinodular goiter. Although the patient's thyroid-stimulating hormone level had become progressively suppressed, the thyroid-stimulating hormone level was within the reference range, at 0.4 mU/mL (reference range 0.35-5.5 mU/mL).
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Media type:  X-RAY

Media file 3:  Nontoxic goiter of the thyroid gland with tracheal compression. Axial noncontrast CT scan through the thyroid shows significant tracheal compression.
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Media type:  CT

Media file 4:  Relief of tracheal compression after subtotal thyroidectomy of large, obstructive, nontoxic, multinodular goiter. (A) Laryngoscopy demonstrating critical tracheal narrowing before thyroidectomy. (B) Laryngoscopy showing widened patent trachea after thyroidectomy.
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Media type:  Photo

Media file 5:  Multinodular goiter. On physical examination (image on left), this patient appears to have a goiter on visual inspection of the neck. The CT scan (image on right) shows the asymmetrical goiter measuring 9.3 X 7.4 cm, with tracheal deviation, though no tracheal obstruction is present.
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Media type:  Photo

Media file 6:  Intrathoracic goiter causing obstruction. This patient has a visible goiter on physical examination. In addition, he has distension of his left external jugular vein, facial erythema (when compared to his shoulder), and cutaneous varicosities of venous blood draining from head into his chest because of jugular obstruction from his goiter.
	View Full Size Image
Media type:  Photo

REFERENCES

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• Berghout A, Wiersinga WM, Drexhage HA, et al. Comparison of placebo with L-thyroxine alone or with carbimazole for treatment of sporadic non-toxic goitre. Lancet. Jul 28 1990;336(8709):193-7. [Medline].
• Bonnema SJ, Bertelsen H, Mortensen J, et al. The feasibility of high dose iodine 131 treatment as an alternative to surgery in patients with a very large goiter: effect on thyroid function and size and pulmonary function. J Clin Endocrinol Metab. Oct 1999;84(10):3636-41. [Medline].
• Braverman LE, Utiger RD, Hermus AR, Huysmans DA:. Clinical manifestations and treatment of nontoxic diffuse and nodular goiter. In: Werner & Ingbar's The Thyroid. Baltimore, Md: Lippincott Williams & Wilkins;. 2000;866-871.
• Hegedus L, Gerber H. Multinodular goiter. In: DeGroot LJ, Jameson JL, eds. Endocrinology. 2001;2:1517-1528.
• Hermus AR, Huysmans DA. Treatment of benign nodular thyroid disease. N Engl J Med. May 14 1998;338(20):1438-47. [Medline].
• Hollowell JG, Staehling NW, Hannon WH, et al. Iodine nutrition in the United States. Trends and public health implications: iodine excretion data from National Health and Nutrition Examination Surveys I and III (1971-1974 and 1988-1994). J Clin Endocrinol Metab. Oct 1998;83(10):3401-8. [Medline].
• Huysmans D, Hermus A, Edelbroek M, et al. Radioiodine for nontoxic multinodular goiter. Thyroid. Apr 1997;7(2):235-9. [Medline].
• Huysmans DA, Hermus AR, Corstens FH, et al. Large, compressive goiters treated with radioiodine. Ann Intern Med. Nov 15 1994;121(10):757-62. [Medline].
• Huysmans DA, Nieuwlaat WA, Erdtsieck RJ, et al. Administration of a single low dose of recombinant human thyrotropin significantly enhances thyroid radioiodide uptake in nontoxic nodular goiter. J Clin Endocrinol Metab. Oct 2000;85(10):3592-6. [Medline].
• Netterville JL, Coleman SC, Smith JC, et al. Management of substernal goiter. Laryngoscope. Nov 1998;108(11 Pt 1):1611-7. [Medline].
• Perrild H, Hansen JM, Hegedus L. Triiodothyronine and thyroxine treatment of diffuse non-toxic goitre evaluated by ultrasonic scanning. Acta Endocrinol (Copenh). Jul 1982;100(3):382-7. [Medline].
• Rios A, Rodriguez JM, Canteras M, Galindo PJ, et al. Surgical management of multinodular goiter with compression symptoms. Arch Surg. Jan 2005;140(1):49-53. [Medline].
• Ross DS. Thyroid hormone suppressive therapy of sporadic nontoxic goiter. Thyroid. Fall 1992;2(3):263-9. [Medline].

Article Last Updated: Jul 14, 2006