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Toxic multinodular goiter

Last reviewed: 3 Nov 2023
Last updated: 26 Oct 2022



History and exam

Key diagnostic factors

  • goiter
More key diagnostic factors

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
Other diagnostic factors

Risk factors

  • iodine deficiency
  • age >40 years
  • head and neck irradiation
  • family history of thyroid nodules
  • female sex
More risk factors

Diagnostic investigations

1st investigations to order

  • thyroid-stimulating hormone (TSH)
More 1st investigations to order

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)
More investigations to consider

Treatment algorithm


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



Elizabeth N. Pearce, MD

Professor of Medicine

Boston University Medical Center




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.


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




PP declares that he has no competing interests.

Ronald Merrell, MD, FACS

Professor of Surgery

Virginia Commonwealth University




RM declares that he has no competing interests.

  • Toxic multinodular goiter images
  • Differentials

    • Graves disease
    • Toxic adenoma
    • Thyrotoxic phase of painless/lymphocytic thyroiditis
    More Differentials
  • Guidelines

    • Thyroid nodule algorithmic tool white paper
    • Definitive surgical management of thyroid disease in adults
    More Guidelines
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