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Simple Nontoxic Goiter

(Euthyroid Goiter)


Jerome M. Hershman

, MD, MS, David Geffen School of Medicine at UCLA

Last full review/revision Sep 2020| Content last modified Sep 2020
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Simple nontoxic goiter, which may be diffuse or nodular, is noncancerous hypertrophy of the thyroid without hyperthyroidism, hypothyroidism, or inflammation. Except in severe iodine deficiency, thyroid function is normal and patients are asymptomatic except for an obviously enlarged, nontender thyroid. Diagnosis is clinical and with determination of normal thyroid function. Treatment is directed at the cause, but partial surgical removal may be required for very large goiters.

Simple nontoxic goiter, the most common type of thyroid enlargement, is frequently noted at puberty, during pregnancy, and at menopause. The cause at these times is usually unclear. Known causes include

  • Intrinsic thyroid hormone production defects

  • Ingestion of foods that contain substances that inhibit thyroid hormone synthesis (goitrogens, eg, cassava, broccoli, cauliflower, cabbage), as may occur in countries in which iodine deficiency is common

  • Drugs that can decrease the synthesis of thyroid hormone (eg, amiodarone or other iodine-containing compounds, lithium)

Iodine deficiency Iodine Deficiency In the body, iodine (I) is involved primarily in the synthesis of 2 thyroid hormones, thyroxine (T4) and triiodothyronine (T3). Iodine occurs in the environment and in the diet primarily as... read more is rare in North America but remains the most common cause of goiter worldwide (termed endemic goiter). Compensatory small elevations in thyroid-stimulating hormone (TSH) occur, preventing hypothyroidism, but the TSH stimulation results in goiter formation. Recurrent cycles of stimulation and involution may result in nontoxic nodular goiters. However, the true etiology of most nontoxic goiters in iodine-sufficient areas is unknown.

Symptoms and Signs of Simple Nontoxic Goiter

The patient may have a history of low iodine intake or overingestion of food goitrogens, but these phenomena are rare in North America. In the early stages, the goiter is typically soft, symmetric, and smooth. Later, multiple nodules and cysts may develop.

Diagnosis of Simple Nontoxic Goiter

  • Thyroidal radioactive iodine uptake

  • Thyroid scan

  • Thyroid ultrasonography

  • Thyroxine (T4), triiodothyronine (T3), and thyroid-stimulating hormone (TSH) levels

In endemic goiter, serum TSH may be slightly elevated, and serum T4 may be low-normal or slightly low, but serum T3 is usually normal or slightly elevated.

Thyroid ultrasonography is done to determine whether there are nodules that are suggestive of cancer.

Treatment of Simple Nontoxic Goiter

  • Depends on cause

In iodine-deficient areas, the following eliminate iodine deficiency:

  • Iodine supplementation of salt

  • Oral administration of iodized oil

  • Intramuscular administration of iodized oil yearly

  • Iodination of water, crops, or animal fodder

Goitrogens being ingested should be stopped.

In other instances, suppression of the hypothalamic-pituitary axis with thyroid hormone blocks thyroid-stimulating hormone (TSH) production (and hence stimulation of the thyroid). Moderate doses of L-thyroxine (100 to 150 mcg orally once a day depending on the serum TSH) are useful in younger patients to reduce the serum TSH to the low-normal range.

L-Thyroxine is contraindicated in older patients with nontoxic nodular goiter, because these goiters rarely shrink and may harbor areas of autonomy so that L-thyroxine therapy can result in hyperthyroidism.

Large goiters occasionally require surgery or iodine-131 to shrink the gland enough to prevent interference with respiration or swallowing or to correct cosmetic problems.

Key Points

  • Thyroid function is usually normal.

  • When the cause is iodine deficiency, iodine supplementation is effective treatment.

  • Blocking thyroid-stimulating hormone production by giving L-thyroxine is useful in younger patients to halt stimulation of the thyroid and shrink the goiter.

  • Surgery or iodine-131 may be needed for large goiters.

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