Evaluation and Management of Multinodular Goiter

Primary Considerations

The American Academy of Otolaryngology-Head and Neck Surgery recommends considering benign multinodular goiter, thyroid malignancy, toxic multinodular goiter, and metastatic disease to cervical lymph nodes from occult primary malignancy when evaluating a multinodular goiter as an anterior neck mass 1

A mass present for 2 weeks or more without significant fluctuation or of uncertain duration strongly suggests malignancy risk, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 3
The absence of infectious etiology increases malignancy concern, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 3, 4
Tobacco and alcohol use are synergistic risk factors for head and neck squamous cell carcinoma, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 3
Associated symptoms such as pharyngitis, dysphagia, or ipsilateral otalgia suggest possible mucosal primary malignancy, according to the American Academy of Otolaryngology-Head and Neck Surgery 3
Fixation to adjacent tissues suggests capsular invasion, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3
Firm consistency (malignant nodes lack tissue edema) is a suspicious feature, according to the American Academy of Otolaryngology-Head and Neck Surgery 3
Size greater than 1.5 cm indicates significant nodal enlargement, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3, 5
Ulceration of overlying skin suggests capsular breakthrough, according to the American Academy of Otolaryngology-Head and Neck Surgery 3

The American Academy of Otolaryngology-Head and Neck Surgery recommends identifying patients at increased risk for malignancy using history, physical exam findings, and other criteria 2, 3, 5
Ultrasound is the initial imaging modality of choice to confirm thyroid origin, characterize morphology, and evaluate nodules using ACR TI-RADS criteria, as stated by Praxis Medical Insights 6, 7
Thyroid function tests (TSH, free T4, free T3) should be obtained to assess for toxic multinodular goiter, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 7
CT neck with contrast is recommended for patients at increased risk for malignancy, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 2, 5, 4, 6
FNA (not open biopsy) should be performed for patients at increased risk when diagnosis remains uncertain, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 5, 4, 7
Examination under anesthesia is recommended before open biopsy for patients at increased risk without diagnosis after FNA, imaging, and ancillary tests, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2, 5

The American Academy of Otolaryngology-Head and Neck Surgery advises against delaying workup with empiric antibiotics in absence of clear infectious signs 2, 4
Cystic masses should not be assumed to be benign, and evaluation should continue until definitive diagnosis, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 5
FNA of dominant nodule alone is not sufficient, and sampling of multiple suspicious nodules is recommended, as noted by Praxis Medical Insights 7
Open biopsy should not be performed before FNA, as FNA is preferred to avoid tumor spillage risk, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 7
Examination under anesthesia should not be skipped before open biopsy in high-risk patients, as it may identify occult primary site, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2