Treatment for Goiters
The type of treatment you receive for a goiter will depend on the size of the goiter and the symptoms associated with it. Small goiters that are causing no problems often require no treatment at all. Goiters that are bigger and causing symptoms, however, do require medical attention. Large, unsightly goiters may even require cosmetic surgery to improve the patient's appearance.
In rare cases, a goiter may grow downward into the chest cavity, causing a substernal goiter that rests against the lungs, trachea, and blood vessels. A substernal goiter may cause coughing and a sensation that something is stuck in the throat. Some people may notice solid foods getting trapped in the upper esophagus and difficulty breathing and lying on their back. Treatment usually involves surgery to remove the thyroid gland and goiter.
Often, treatment of the underlying problem — such as hyperthyroidism or hypothyroidism — is enough to shrink the goiter. (See Chapters 5 and 8 for specific treatments.) With patients who have euthyroid goiter, some doctors may try giving what is called levothyroxine suppressive therapy, which suppresses TSH levels. But levothyroxine suppressive therapy rarely works, and most patients wind up with hyperthyroidism.
Toxic Multinodular Goiters
Treating a toxic multinodular goiter is somewhat trickier. Unlike the goiters that occur in Graves' disease, toxic multinodular goiters do not go into remission and don't respond to antithyroid medications. Instead, treatment typically involves RAI or surgery to definitively remove the goiter.
Sometimes, patients with a toxic multinodular goiter will not have the ability to take up high levels of RAI, the way diseased thyroid tissue in Graves' disease does. This situation can make it hard for the goiter to absorb the RAI that is necessary to kill the diseased tissue. In these cases, patients may be pretreated with lithium or recombinant TSH to enhance iodine uptake and RAI treatment. RAI may be especially useful in elderly patients and others in whom surgery is considered high risk.
Most patients treated with RAI for toxic multinodular goiter often get only an ablation of their hot areas. Since the remaining tissue is not affected by the disease process, hypothyroidism is not likely to occur.
But in some patients, surgery may be the only alternative. People who have large goiters that are causing compression, for example, are good candidates for surgery. Surgery is also used in cases when RAI is impractical or has been ineffective.
Often, nontoxic goiters cause no symptoms at all, so no treatment is required. Some doctors may use RAI or surgery, especially in cases where a nontoxic goiter causes compression or is large. In patients with nontoxic goiters who receive RAI, the goiter can sometimes shrink. In general, the higher the uptake of iodine, the more likely the goiter will shrink.