Multinodular and Retrosternal Goiter

  • Rachel Rosenthal
  • Daniel Oertli


Multinodular goiter is a quite common condition with a marked female preponderance and it affects about 13% of the world population. Large differences in goiter prevalence have been found in different regions: 37.3% in the Eastern Mediterranean area, 28.3% in Africa, 20.6% in Europe, 15.4% in Southeast Asia, 6.1% in the Western Pacific, and 4.7% in the Americas. The cause of multinodular goiter remains unclear but is probably multifactorial. Iodine deficiency, naturally occurring goitrogens, drugs, thyroid growth factors, and heredity have been postulated as possible contributors to goiter development.


Total Thyroidectomy Iodine Deficiency Multinodular Goiter Urinary Iodine Nodular Goiter 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Agarwal G, Aggarwal V (2008) Is total thyroidectomy the surgical procedure of choice for benign multinodular goiter? An evidence-based review. World J Surg 32:1313–1324PubMedCrossRefGoogle Scholar
  2. 2.
    Allo MD, Thompson NW (1983) Rationale for the operative management of substernal goiters. Surgery 94:969–977PubMedGoogle Scholar
  3. 3.
    Andersson M, Takkouche B, Egli I, Allen HE, de Benoist B (2005) Current global iodine status and progress over the last decade towards the elimination of iodine deficiency. Bull World Health Organ 83:518–525PubMedGoogle Scholar
  4. 4.
    Baloch ZW, Fleisher S, LiVolsi VA, Gupta PK (2002) Diagnosis of ‘follicular neoplasm’: a gray zone in thyroid fine-needle aspiration cytology. Diagn Cytopathol 26(1):41–44PubMedCrossRefGoogle Scholar
  5. 5.
    Baloch ZW, LiVolsi VA (2008) Fine-needle aspiration of the thyroid: today and tomorrow. Best Pract Res Clin Endocrinol Metab 22(6):929–939PubMedCrossRefGoogle Scholar
  6. 6.
    Barczyński M, Konturek A, Cichoń S (2009) Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy. Br J Surg 96:240–246PubMedCrossRefGoogle Scholar
  7. 7.
    Barczyński M, Konturek A, Hubalewska-Dydejczyk A, Gołkowski F, Cichoń S, Nowak W (2010) Five-year follow-up of a randomized clinical trial of total thyroidectomy versus Dunhill operation versus bilateral subtotal thyroidectomy for multinodular nontoxic goiter. World J Surg 34(6):1203–1213PubMedCrossRefGoogle Scholar
  8. 8.
    Barczyński M, Konturek A, Gołkowski F, Hubalewska-Dydejczyk A, Cichoń S, Nowak W (2010) Five-year follow-up of a randomized clinical trial of unilateral thyroid lobectomy with or without postoperative levothyroxine treatment. World J Surg 34(6):1232–1238PubMedCrossRefGoogle Scholar
  9. 9.
    Belmont MJ, Wax MK, DeSouza FN (1998) The difficult airway: cardiopulmonary bypass – the ultimate solution. Head Neck 20:266–269PubMedCrossRefGoogle Scholar
  10. 10.
    Bergamaschi R, Becouarn G, Ronceray J, Arnaud JP (1998) Morbidity of thyroid surgery. Am J Surg 176:71–75PubMedCrossRefGoogle Scholar
  11. 11.
    Bischof P (2004) Update endocrinology: thyroid sonography. Schweiz Rundsch Med Prax 93:695–700Google Scholar
  12. 12.
    Bonnema SJ, Hegedüs L (2009) A 30-year perspective on radioiodine therapy of benign nontoxic multinodular goiter. Curr Opin Endocrinol Diabetes Obes 16(5):379–384PubMedCrossRefGoogle Scholar
  13. 13.
    Brix TH, Kyvik KO, Hegedus L (1999) Major role of genes in the etiology of simple goiter in females: a population-based twin study. J Clin Endocrinol Metab 84:3071–3075PubMedCrossRefGoogle Scholar
  14. 14.
    Bron LP, O’Brien CJ (2004) Total thyroidectomy for clinically benign disease of the thyroid gland. Br J Surg 91:569–574PubMedCrossRefGoogle Scholar
  15. 15.
    Buhr HJ, Mann B (1999) Thyroidectomy and lymphadenectomy. Chirurg 70:987–998PubMedCrossRefGoogle Scholar
  16. 16.
    Celani MF (1993) Levothyroxine suppressive therapy in the medical management of nontoxic benign multinodular goiter. Exp Clin Endocrinol 101:326–332PubMedCrossRefGoogle Scholar
  17. 17.
    Cheung PS, Lee JM, Boey JH (1989) Thyroxine suppressive therapy of benign solitary thyroid nodules: a prospective randomized study. World J Surg 13:818–821PubMedCrossRefGoogle Scholar
  18. 18.
    De Benoist B, McLean E, Andersson M, Rogers L (2008) Iodine deficiency in 2007: global progress since 2003. Food Nutr Bull 29(3):195–202PubMedGoogle Scholar
  19. 19.
    Delange F, Bastani S, Benmiloud M et al (1986) Definitions of endemic goiter and cretinism, classification of goiter size and severity of endemias, and survey techniques. In: Dunn JT, Pretell A, Daza CH et al (eds) Towards the eradication of endemic goiter, cretinism, and iodine deficiency. Pan American Health Organization, World Health Organization, Washington, DC, pp 373–376Google Scholar
  20. 20.
    Delange F, Burgi H, Chen ZP et al (2002) World status of monitoring iodine deficiency disorders control programs. Thyroid 12:915–924PubMedCrossRefGoogle Scholar
  21. 21.
    Delbridge L, Guinea AI, Reeve TS (1999) Total thyroidectomy for bilateral benign multinodular goiter: effect of changing practice. Arch Surg 134:1389–1393PubMedCrossRefGoogle Scholar
  22. 22.
    DeLellis RA, Loyd R, Heitz PU, Eng C (eds) (2004) WHO classification of tumours: pathology and genetics of tumors of endocrine organs. IARC Press, LyonGoogle Scholar
  23. 23.
    Derwahl M, Studer H (1998) Pathogenesis and treatment of multinodular goiter. In: Fagin JA (ed) Thyroid cancer. Kluwer, Boston, pp 155–186CrossRefGoogle Scholar
  24. 24.
    Derwahl M, Studer H (2000) Multinodular goiter: much more than simply iodine deficiency. Baillieres Best Pract Res Clin Endocrinol Metab 14:577–600PubMedCrossRefGoogle Scholar
  25. 25.
    Derwahl M, Studer H (2001) Nodular goiter and goiter nodules: where iodine deficiency falls short of explaining the facts. Exp Clin Endocrinol Diabetes 109:250–260PubMedCrossRefGoogle Scholar
  26. 26.
    Derwahl M, Studer H (2002) Hyperplasia versus adenoma in endocrine tissues: are they different? Trends Endocrinol Metab 13:23–28PubMedCrossRefGoogle Scholar
  27. 27.
    Derwahl KM, Zielke A, Rothmund M (2000) Euthyreote knotenstruma. In: Siewert JR, Harder F, Rothmund M (eds) Endokrine chirurgie. Springer, Berlin/Heidelberg/New York, pp 63–88Google Scholar
  28. 28.
    Dralle H (2009) Rekurrens- und Nebenschilddrüsenpräparation in der Schilddrüsenchirurgie. Chirurg 80:352–363PubMedCrossRefGoogle Scholar
  29. 29.
    Dunn JT, Semigran MJ, Delange F (1998) The prevention and management of iodine-induced hyperthyroidism and its cardiac features. Thyroid 8:101–106PubMedCrossRefGoogle Scholar
  30. 30.
    Efremidou EI, Papageorgiou MS, Liratzopoulos N, Manolas KJ (2009) The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: a review of 932 cases. Can J Surg 52(1):39–44PubMedGoogle Scholar
  31. 31.
    Eszlinger M, Paschke R (2010) Molecular fine needle aspiration biopsy diagnosis of thyroid nodules by utmor specific mutations and gene expression patterns. Mol Cell Endocrinol 322:29–37PubMedCrossRefGoogle Scholar
  32. 32.
    Eszlinger M, Krohn K, Hauptmann S, Dralle H, Giordano TJ, Paschke R (2008) Perspectives for improved and more accurate classification of thyroid epithelial tumors. J Clin Endocrinol Metab 93:3286–3294PubMedCrossRefGoogle Scholar
  33. 33.
    Farling PA (2000) Thyroid disease. Br J Anaesth 85:15–28PubMedCrossRefGoogle Scholar
  34. 34.
    Fast S, Nielsen VE, Bonnema SJ, Hegedüs L (2009) Time to reconsider nonsurgical therapy of benign non-toxic multinodular goitre: focus on recombinant human TSH augmented radioiodine therapy. Eur J Endocrinol 160(4):517–528PubMedCrossRefGoogle Scholar
  35. 35.
    Gardiner KR, Russell CF (1995) Thyroidectomy for large multinodular colloid goitre. J R Coll Surg Edinb 40:367–370PubMedGoogle Scholar
  36. 36.
    Gérard AC, Poncin S, Caetano B, Sonveaux P, Audinot JN, Feron O, Colin IM, Soncin F (2008) Iodine deficiency induces a thyroid stimulating hormone-independent early phase of microvascular reshaping in the thyroid. Am J Pathol 172(3):748–760PubMedCrossRefGoogle Scholar
  37. 37.
    Gharib H, James EM, Charboneau JW et al (1987) Suppressive therapy with levothyroxine for solitary thyroid nodules. A double-blind controlled clinical study. N Engl J Med 317:70–75PubMedCrossRefGoogle Scholar
  38. 38.
    Gibelin H, Sierra M, Mothes D, Ingrand P, Levillain P, Jones C, Hadjadj S, Torremocha F, Marechaud R, Barbier J, Kraimps JL (2004) Risk factors for recurrent nodular goiter after thyroidectomy for benign disease: case–control study of 244 patients. World J Surg 28:1079–1082PubMedCrossRefGoogle Scholar
  39. 39.
    Gittoes NJ, Miller MR, Daykin J et al (1996) Upper airways obstruction in 153 consecutive patients presenting with thyroid enlargement. BMJ 312:484PubMedCrossRefGoogle Scholar
  40. 40.
    Hedinger C, Williams ED, Sobin LH (1988) World Health Organization (ed) International histological classification of tumours. Histological typing of thyroid tumours. Springer, Berlin/Heidelberg/New YorkGoogle Scholar
  41. 41.
    Hedinger C, Williams ED, Sobin LH (1989) The WHO histological classification of thyroid tumors: a commentary on the second edition. Cancer 63:908–911PubMedCrossRefGoogle Scholar
  42. 42.
    Hegedus L (2001) Thyroid ultrasound. Endocrinol Metab Clin North Am 30:339–360PubMedCrossRefGoogle Scholar
  43. 43.
    Hermann M, Alk G, Roka R, Glaser K, Freissmuth M (2002) Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Ann Surg 235(2):261–268PubMedCrossRefGoogle Scholar
  44. 44.
    Hung OR, Stewart RD (1996) Illuminating stylet (light wand). In: Benumhof JL (ed) Airway management. Principles and practice. Mosby, St. Louis, pp 342–352Google Scholar
  45. 45.
    Iared W, Shigueoka DC, Cristófoli JC, Andriolo R, Atallah AN, Ajzen SA, Valente O (2010) Use of color Doppler ultrasonography for the prediction of malignancy in follicular thyroid neoplasms: systematic review and meta-analysis. J Ultrasound Med 29(3):419–425PubMedGoogle Scholar
  46. 46.
    Kann P, Jocham A, Beyer J (1997) Hypothyroidism, hyperthyroidism and therapy with thyroid hormones: effect on the skeletal system. Dtsch Med Wochenschr 122:1392–1397PubMedCrossRefGoogle Scholar
  47. 47.
    Karkouti K, Rose DK, Wigglesworth D et al (2000) Predicting difficult intubation: a multivariable analysis. Can J Anaesth 47:730–739PubMedCrossRefGoogle Scholar
  48. 48.
    Kobberling J, Hintze G (1999) Differential indications for thyroid gland operation. Chirurg 70:971–979PubMedCrossRefGoogle Scholar
  49. 49.
    Koc M, Ersoz HO, Akpinar I, Gogas-Yavuz D, Deyneli O, Akalin S (2002) Effect of low- and high-dose levothyroxine on thyroid nodule volume: a crossover placebo-controlled trial. Clin Endocrinol 57:621–628CrossRefGoogle Scholar
  50. 50.
    Koh YW, Park JH, Lee SW, Choi EC (2008) The harmonic scalpel technique without supplementary ligation in total thyroidectomy with central neck dissection: a prospective randomized study. Ann Surg 247(6):945–949PubMedCrossRefGoogle Scholar
  51. 51.
    Lima N, Knobel M, Cavaliere H et al (1997) Levothyroxine suppressive therapy is partially effective in treating patients with benign, solid thyroid nodules and multinodular goiters. Thyroid 7:691–697PubMedCrossRefGoogle Scholar
  52. 52.
    Lisboa HR, Gross JL, Orsolin A et al (1996) Clinical examination is not an accurate method of defining the presence of goitre in schoolchildren. Clin Endocrinol (Oxf) 45:471–475CrossRefGoogle Scholar
  53. 53.
    Liu Q, Djuricin G, Prinz RA (1998) Total thyroidectomy for benign thyroid disease. Surgery 123:2–7PubMedCrossRefGoogle Scholar
  54. 54.
    Manders JMB, Corstens FHM (2002) Radioiodine therapy of euthyroid multinodular goiters. Eur J Nucl Med 29:S466–S470CrossRefGoogle Scholar
  55. 55.
    Mann B, Schmale P, Stremmel W (1996) Thyroid morphology and function after surgical treatment of thyroid diseases. Exp Clin Endocrinol Diabetes 104:271–277PubMedCrossRefGoogle Scholar
  56. 56.
    Marchesi M, Biffoni M, Tartaglia F et al (1998) Total versus subtotal thyroidectomy in the management of multinodular goiter. Int Surg 83:202–204PubMedGoogle Scholar
  57. 57.
    Martin L, Delbridge L, Martin J, Poole A, Crummer P, Reeve TS (1989) Trainee surgery in teaching hospitals: is there a cost ? Aust N Z J Surg 59:257–260PubMedCrossRefGoogle Scholar
  58. 58.
    Ménegaux F, Turpin G, Dahman M, Leenhardt L, Chadarevian R, Aurengo A, du Pasquier L, Chigot JP (1999) Secondary thyroidectomy in patients with prior thyroid surgery for benign disease: a study of 203 cases. Surgery 126:479–483PubMedCrossRefGoogle Scholar
  59. 59.
    Mishra A, Agarwal A, Agarwal G, Mishra SK (2001) Total thyroidectomy for benign thyroid disorders in an endemic region. World J Surg 25:307–310PubMedCrossRefGoogle Scholar
  60. 60.
    Muller PE, Schmid T, Spelsberg F (1998) Total thyroidectomy in iodine-deficient goiter: an effective treatment alternative? Zentralbl Chir 123:39–41PubMedGoogle Scholar
  61. 61.
    Muller PE, Jakoby R, Heinert G et al (2001) Surgery for recurrent goitre: its complications and their risk factors. Eur J Surg 167:816–821PubMedCrossRefGoogle Scholar
  62. 62.
    Netterville JL, Coleman SC, Smith JC et al (1998) Management of substernal goiter. Laryngoscope 108:1611–1617PubMedCrossRefGoogle Scholar
  63. 63.
    Papini E, Bacci V, Panunzi C et al (1993) A prospective ­randomized trial of levothyroxine suppressive therapy for solitary thyroid nodules. Clin Endocrinol (Oxf) 38:507–513CrossRefGoogle Scholar
  64. 64.
    Pappalardo G, Guadalaxara A, Frattaroli FM, Illomei G, Falaschi P (1998) Total compared with subtotal thyroidectomy in benign nodular disease: personal series and review of published reports. Eur J Surg 164:501–506PubMedCrossRefGoogle Scholar
  65. 65.
    Peters H, Hackel D, Schleusener H (1996) The prevention of the recurrence of endemic goiter. The efficacy of a once-a-week dose of 1.53 mg iodide. Dtsch Med Wochenschr 121:752–756PubMedCrossRefGoogle Scholar
  66. 66.
    Piraneo S, Vitri P, Galimberti A, Guzzetti S, Salvaggio A, Bastagli A (1994) Recurrence of goitre after operation in euthyroid patients. Eur J Surg 160:351–356PubMedGoogle Scholar
  67. 67.
    Prades JM, Dumollard JM, Timoshenko A et al (2002) Multinodular goiter: surgical management and histopathological findings. Eur Arch Otorhinolaryngol 259:217–221PubMedGoogle Scholar
  68. 68.
    Rasmussen SN, Hjorth L (1974) Determination of thyroid volume by ultrasonic scanning. J Clin Ultrasound 2:143–147PubMedCrossRefGoogle Scholar
  69. 69.
    Rios-Zambudio A, Rodriguez J, Riquelme J, Soria T, Canteras M, Parrilla P (2004) Prospective study of postoperative complications after total thyroidectomy for multinodular goiters by surgeons with experience in endocrine surgery. Ann Surg 240:18–25CrossRefGoogle Scholar
  70. 70.
    Röher HD (1999) Surgical technique: thyroid gland surgery 1999. Current challenges of problem-oriented thyroid gland surgery. Chirurg 70:969–970PubMedCrossRefGoogle Scholar
  71. 71.
    Röher HD, Goretzki PE, Hellmann P et al (1999) Complications in thyroid surgery. Incidence and therapy. Chirurg 70:999–1010PubMedCrossRefGoogle Scholar
  72. 72.
    Rojdmark J, Jarhult J (1995) High long term recurrence rate after subtotal thyroidectomy for nodular goitre. Eur J Surg 161:725–727PubMedGoogle Scholar
  73. 73.
    Rose DK, Cohen MM (1994) The airway: problems and predictions in 18,500 patients. Can J Anaesth 41:372–383PubMedCrossRefGoogle Scholar
  74. 74.
    Rowe-Jones JM, Rosswick RP, Leighton SE (1993) Benign thyroid disease and vocal cord palsy. Ann R Coll Surg Engl 75:241–244PubMedGoogle Scholar
  75. 75.
    Salabe GB (2001) Pathogenesis of thyroid nodules: histological classification? Biomed Pharmacother 55(1):39–53PubMedCrossRefGoogle Scholar
  76. 76.
    Samraj K, Gurusamy KS (2007) Wound drains following thyroid surgery. Cochrane Database Syst Rev. (4):CD006099Google Scholar
  77. 77.
    Sawin CT, Geller A, Wolf PA et al (1994) Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med 331:1249–1252PubMedCrossRefGoogle Scholar
  78. 78.
    Siragusa G, Lanzara P, Di Pace G (1998) Subtotal thyroidectomy or total thyroidectomy in the treatment of benign thyroid disease. Our experience. Minerva Chir 53:233–238PubMedGoogle Scholar
  79. 79.
    Snook KL, Stalberg PL, Sidhu SB, Sywak MS, Edhouse P, Delbridge L (2007) Recurrence after total thyroidectomy for benign multinodular goiter. World J Surg 31(3):593–598PubMedCrossRefGoogle Scholar
  80. 80.
    Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R (1998) The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 228:320–330PubMedCrossRefGoogle Scholar
  81. 81.
    Spencer CA, Schwarzbein D, Guttler RB et al (1993) Thyrotropin (TSH)-releasing hormone stimulation test responses employing third and fourth generation TSH assays. J Clin Endocrinol Metab 76:494–498PubMedCrossRefGoogle Scholar
  82. 82.
    Steinmuller T, Ulrich F, Rayes N et al (2001) Surgical procedures and risk factors in therapy of benign multinodular goiter. A statistical comparison of the incidence of complications. Chirurg 72:1453–1457PubMedCrossRefGoogle Scholar
  83. 83.
    Stubner D, Gartner R, Greil W et al (1987) Hypertrophy and hyperplasia during goitre growth and involution in rats: separate bioeffects of TSH and iodine. Acta Endocrinol (Copenh) 116:537–548Google Scholar
  84. 84.
    Studer H, Derwahl M (1995) Mechanisms of nonneoplastic endocrine hyperplasia – a changing concept: a review focused on the thyroid gland. Endocr Rev 16:411–426PubMedGoogle Scholar
  85. 85.
    Tezelman S, Borucu I, Senyurek Giles Y, Tunca F, Terzioglu T (2009) The change in surgical practice from subtotal to near-total or total thyroidectomy in the treatment of patients with benign multinodular goiter. World J Surg 33(3):400–405PubMedCrossRefGoogle Scholar
  86. 86.
    Thomusch O, Machens A, Sekulla C, Ukkat J, Lippert H, Gastinger I, Dralle H (2000) Multivariate analysis of risk factors for postoperative complications in benign goiter surgery: prospective multicenter study in Germany. World J Surg 24:1335–1341PubMedCrossRefGoogle Scholar
  87. 87.
    Tonacchera M, Pinchera A, Vitti P (2010) Assessment of nodular goiter. Best Pract Res Clin Endocrinol Metab 24(1):51–61PubMedCrossRefGoogle Scholar
  88. 88.
    Wagner PK (1999) Surgical techniques for benign goiter. Chirurg 70:980–986PubMedCrossRefGoogle Scholar
  89. 89.
    Weber AL, Randolph G, Aksoy FG (2000) The thyroid and parathyroid glands. CT and MR imaging and correlation with pathology and clinical findings. Radiol Clin North Am 38:1105–1129PubMedCrossRefGoogle Scholar
  90. 90.
    Wémeau JL, Caron P, Schvartz C, Schlienger JL, Orgiazzi J, Cousty C, Vlaeminck-Guillem V (2002) Effects of thyroid-stimulating hormone suppression with levothyroxine in reducing the volume of solitary thyroid nodules and improving extranodular nonpalpable changes. J Clin Endocrinol Metab 87:4928–4934PubMedCrossRefGoogle Scholar
  91. 91.
    Wheeler MH (1999) Clinical dilemma. Retrosternal goitre. Br J Surg 86:1235–1236PubMedCrossRefGoogle Scholar
  92. 92.
    WHO, UNICEF, and ICCIDD (1993) Indicators for assessing iodine deficiency disorders and their control programmes. Oct 26 2010
  93. 93.
    Wilson DB, Staren ED, Prinz RA (1998) Thyroid reoperations: indications and risks. Am Surg 64:674–678PubMedGoogle Scholar
  94. 94.
    Winbladh A, Järhult J (2008) Fate of the non-operated, non-toxic goitre in a defined population. Br J Surg 95(3):338–343PubMedCrossRefGoogle Scholar
  95. 95.
    Wright CD, Mathisen DJ (2001) Mediastinal tumors: diagnosis and treatment. World J Surg 25:204–209PubMedCrossRefGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of Surgery, General Surgery and Clinical ResearchUniversity Hospital BaselBaselSwitzerland
  2. 2.Division of General Surgery, Department of SurgeryUniversity Hospital BaselBaselSwitzerland

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