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Toxic multinodular goiter

  • Overview
  • Theory
  • Diagnosis
  • Management
  • Follow up
  • Resources
Last reviewed: 18 Sep 2025
Last updated: 26 Oct 2022

Summary

Definition

History and exam

Key diagnostic factors

  • goiter
Full details

Other diagnostic factors

  • heat intolerance, hyperphagia, or weight loss
  • depression
  • nervousness or palpitations
  • oligomenorrhea
  • hyperdefecation
  • stare or lid lag
  • warm, moist skin
  • tachycardia
  • irregular pulse
  • tremor
  • muscle weakness
  • shortness of breath or choking sensation
  • Pemberton sign
Full details

Risk factors

  • iodine deficiency
  • age >40 years
  • head and neck irradiation
  • family history of thyroid nodules
  • female sex
Full details

Diagnostic investigations

1st investigations to order

  • thyroid-stimulating hormone (TSH)
Full details

Investigations to consider

  • free T4 (or total T4 with a measure of binding)
  • total T3 with a measure of binding (or free T3)
  • I-123 thyroid scan and uptake
  • Tc-99 pertechnetate scan
  • thyroid ultrasound
  • metabolic panel
  • CBC
  • thyroid peroxidase antibodies
  • TSH receptor antibodies
  • ECG
  • CT neck (noncontrast)
Full details

Treatment algorithm

ONGOING

nonpregnant nonlactating adults: without mass effect or suspicion of cancer

mass effect or suspicion of cancer

pregnant or lactating: without mass effect or suspicion of cancer

Contributors

Authors

Elizabeth N. Pearce, MD

Professor of Medicine

Boston University Medical Center

Boston

MA

Disclosures

ENP is a member of the Management Council of the Iodine Global Network. She was the 2018-2019 President of the American Thyroid Association (ATA) and served on its board and executive committee until 2020. She is a current member of the ATA's thyroid in pregnancy guidelines writing task force. She is currently a Deputy Editor at the Journal of Clinical Endocrinology and Metabolism and has previously served as an Associated Editor for the journals Thyroid, Endocrine Practice, and Clinical Thyroidology. She is an author of a number of references cited in this topic.

Acknowledgements

Dr Elizabeth N. Pearce would like to gratefully acknowledge Dr Sheila Feit, a previous contributor to this topic. SF was previously employed by BMJ.

Peer reviewers

Petros Perros, BSc, MBBS, MD, FRCP

Consultant Endocrinologist

Freeman Hospital

Newcastle-Upon-Tyne

UK

Disclosures

PP declares that he has no competing interests.

Ronald Merrell, MD, FACS

Professor of Surgery

Virginia Commonwealth University

Richmond

VA

Disclosures

RM declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Gharib H, Papini E, Garber JR, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules - 2016 update. Endocr Pract. 2016 May;22(5):622-39.Full text  Abstract

Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol. 2015 Apr;3(4):286-95. Abstract

Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26:1343-1421.Full text  Abstract

Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1-133.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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