Alternative names for multinodular goitre

Multinodular goiter; MNG; nodular goitre

What is multinodular goitre?

The thyroid gland is a butterfly-shaped gland sitting at the front of the neck. It is responsible for the production and release of thyroid hormones (thyroxine and triiodothyronine). Any increase in the size of the whole, or part of, the thyroid gland is called a goitre. For more information see the article on goitre. A multinodular goitre is a goitre where there are many lumps (nodules) that appear within the gland. This is probably the most common thyroid gland disorder. Nodules may be clearly visible or only discovered through examination or scans.

How common is multinodular goitre?

The prevalence of goitres varies depending on the location and iodine intake of the population. Multinodular goitre and thyroid disease in general, are much more common in women than in men. There is also clear evidence of an increase with age, partly due to the fact that multinodular goitre is formed over a long period of time. Ultrasound examination of the thyroid gland will reveal nodules in more than half of women aged 50 or over. There is no reason for most patients to worry about this finding and, as long as the thyroid gland is working normally, many people will not require medical treatment.

What causes multinodular goitre?

The cause(s) of multinodular goitre are, in most cases, unknown. A simple and diffuse goitre may develop into a multinodular goitre over time. The following risk factors have been identified: iodine deficiency, female gender, increasing age and family history of multinodular goitre.

Over a period of time, nodules are formed due to different rates of growth in different parts of the gland, possibly combined with other external influences such as diet drugs or genes.

The nodules lead to an irregular knobbly appearance in the structure of the thyroid gland. This process takes many years, so it is common to find an increase in the number of people with multinodular goitre as people become older.

Is multinodular goitre inherited?

Some forms of goitre can be inherited. There is some evidence that the presence of goitre in one family member increases the chances of other family members having goitre. However, our knowledge of genes and genetic problems is increasing all the time and more precise information is likely to be available in the future, including the effects of specific genes and the environment on goitre.

What are the signs and symptoms of multinodular goitre?

In many cases, multinodular goitres appear as a lump in the front of the neck and can be visible even if the thyroid is working normally (i.e. the person is euthyroid). Usually, multinodular goitre is not visible and is only discovered when a patient is being examined or scanned for other reasons as in majority of cases they do not cause any symptoms.

At times there are symptoms of an overactive (hyperthyroid) or underactive (hypothyroid) thyroid gland. (See the articles on thyroid hormone and thyrotoxicosis.)

• An overactive thyroid gland may be associated with weight loss, trembling hands, palpitations, intolerance of heat, sleep disturbances, anxiety and increased bowel movement
• An underactive thyroid gland may be associated with weight gain, dry skin, muscle cramps, intolerance to cold, low mood and constipation

Very large goitres may be associated with difficulty with swallowing or breathing, hoarseness of the voice or a tight feeling around the throat and can, in some cases, require surgical removal. Less commonly, multinodular goitre can cause pain or discomfort from a rapid increase in size. This may be due to a sudden build-up of fluid or blood within a nodule or very rarely, due to a tumour.

How is multinodular goitre diagnosed?

Multinodular goitres are often found when people are being examined or when a scan of the neck is performed for another reason.

Apart from taking an initial thorough medical and family history, the patient’s doctor will also examine for physical symptoms and test hormone levels in the blood. Scans of the neck such as an ultrasound scan or CT scan may be carried o to gather more information. In some cases, patients may then be referred to see a surgeon, or a hormone specialist (an endocrinologist). For details on further tests, see the article on goitre.

How is multinodular goitre treated?  

It is important to establish whether or not the thyroid gland is functioning normally. Most patients will have a normally functioning, but lumpy thyroid gland that will never harm them and do not require any treatment.

The requirement for treatment is based on the effect of the thyroid gland on surrounding structures and function of the thyroid gland.-If function is normal (euthyroid), the goitre is not causing any local structural problems, and if there is no concern about any abnormal areas within the gland, the only form of management likely to be required would be regular monitoring of thyroid function. If there were any structural problems, these would usually be apparent in the ultrasound scan performed at the time of diagnosis. Other tests or treatment would be recommended if there was a change in this situation.

• In the case of an underactive thyroid (hypothyroidism) with no other symptoms of concern, thyroxine therapy would be given which may, over a period of time, help to slightly reduce the goitre’s size, especially in cases where there is a history of iodine deficiency.
• In the case of an overactive thyroid (hyperthyroidism), the terms ‘toxic multinodular goitre’ or ‘multinodular goitre with thyrotoxicosis’ may be used. This overactivity may be subtle and picked up only in blood tests (this is called ‘subclinical thyrotoxicosis’), or clearly overactive (see the article on thyrotoxicosis). Tablets, such as carbimazole, can be used in the short term to control secretion of thyroid hormones while the diagnosis is being established and further treatments are being considered.

Treatment with drugs such as carbimazole can help control thyroid overactivity but this does not lead to a cure, and thyroid overactivity is likely to return if the treatment is stopped. In such instances, surgical treatment or radioactive iodine treatment (also known as radioiodine) may be considered for a more permanent treatment of the overactive thyroid. Some patients opt to continue carbimazole over the long term to control thyroid overactivity.

Occasionally, surgery to remove all or most of the thyroid can be carried out, particularly in the following cases.

• If a multinodular goitre is large, causing symptoms due to compression of the nearby structures and/or the patient feels it is unsightly. However, removing a normally functioning gland can leave a patient requiring thyroxine for life
• If there are areas of concern on a thyroid scan or fine needle aspiration biopsy.
• In certain cases of toxic nodular goitre which produces excess amounts of thyroid hormone.

For further treatment options, see the article on goitre.

Are there any side-effects to the treatment?

The side-effects are the same as those for the treatment of goitre.

What are the longer-term implications of multinodular goitre?  

A multinodular goitre that is not causing any symptoms, is unlikely to cause problems in the long term. It is, however, important that thyroid function tests are performed by the doctor periodically to determine whether any future treatment is needed.

Are there patient support groups for people with multinodular goitre?

The British Thyroid Foundation may be able to provide advice and support to patients and their families dealing with multinodular goitre.