**4. Clinical evaluation of MNG**

MNG is usually detected incidentally during routine examination for evaluation of some other disease. Sometimes the patient seeks help for obvious neck swelling and cosmetic disfigurement of the neck. As MNG becomes palpable once the size is more than 1 centimeter, so large MNG mainly presents with neck swelling. Once MNG is detected, a complete history and physical examination focusing on the thyroid gland and adjacent cervical lymph nodes should be performed. Through history including history of childhood head and neck radiation therapy, total body radiation for bone marrow transplantation, exposure to ionizing radiation from fallout in childhood or adolescence, familial thyroid carcinoma, or thyroid cancer syndrome should be sought [27, 28]. Patients with long-standing MNG are more

**103**

*Multinodular Goiter*

further evaluation.

**6. Imaging study**

**6.2 Radionuclide scan**

**5. Laboratory investigation**

with imaging and FNAC [29–30].

**6.1 Thyroid ultrasonography**

ultrasound guided FNAC for greater yield in diagnosis.

*DOI: http://dx.doi.org/10.5772/intechopen.90325*

likely to have clinical features of thyrotoxicosis, and they usually present with subclinical or clinical hyperthyroidism during evaluation. The MNG may present with compressive features, i.e., dyspnea and dysphagia. Respiratory symptoms develop due to tracheal compression. Hoarseness of voice may result from compression of recurrent laryngeal nerve. Very rarely MNG may present with vocal cord palsy, but it is usually seen in malignancy. Retrosternal MNG with thoracic inlet compression can be diagnosed with Pemberton's maneuver, in which raising arm overhead causes flushing and shortness of breath due to compression of neck veins. Information regarding family members, any significant drug use, and radiation exposure should also be enquired. Thyroid examination should be done in sitting position, and during palpation information regarding thyroid shape, nodularity, tenderness, and fixity to the surrounding should be sought. Fixation to trachea, esophagus, and surrounding structure raises the possibility of malignancy. Enlarged painful and tender thyroid can be due to subacute thyroiditis or thyroid abscess. Neck mass with enlarged cervical lymph node again raises suspicion of carcinoma and warrants

American Thyroid Association (ATA) recommends serum TSH as the initial laboratory test in evaluation of MNG. If serum TSH is abnormal, then serum FT4 and serum FT3 are recommended to know the thyroid's functioning status. Antithyroid peroxidase (anti TPO) antibody and thyroglobulin (Tg) are other laboratory tests to know about thyroid autoimmunity and Tg gene mutation in patients with MNG. If TSH is high, the risk of malignancy is increased, so it warrants further evaluation

Thyroid ultrasound is the most widely accepted imaging modality to know the characteristic of MNG. Ultrasound can give information regarding the number of nodules and the size and location of nodules within the thyroid. It also provides information regarding the presence or absence of any suspicious cervical lymph nodes in the neck. Thyroid sonography can also describe features including composition (solid, cystic proportion, or spongiform), echogenicity, margins, presence and type of calcifications, shape if taller than wide, and vascularity which helps in making decision of FNAC (**Figure 1**). Thyroid ultrasound is commonly used in

Although radionuclide imaging of thyroid gland has been done for a long time, resolution of this modality for thyroid nodule is far behind the ultrasonography [31]. So radionuclide imaging is not having much role in anatomic description of MNG. However radionuclide imaging is very useful in describing physiology of thyroid nodules. If TSH is subnormal, then ATA recommends a radionuclide thyroid scan to know whether nodules are hyperfunctioning ("hot," i.e., tracer uptake is greater than the surrounding normal thyroid), isofunctioning ("warm,"

### *Multinodular Goiter DOI: http://dx.doi.org/10.5772/intechopen.90325*

*Goiter - Causes and Treatment*

**3.3 Hashitoxicosis**

**3.5 Riedel's thyroiditis**

**4. Clinical evaluation of MNG**

confirmation.

interferon α, and alemtuzumab [20–22]. Other autoimmune manifestations associated with Graves' disease are pretibial myxedema and ophthalmopathy. Graves' disease is the most common cause of thyrotoxicosis [23]. It is more common in females and usually presents before 30 years of age. Graves' disease presents with classical symptoms of thyrotoxicosis, i.e., irritability, sleeplessness, palpitations,

Hashitoxicosis, a term coined from Hashimoto's disease and thyrotoxicosis, is a rare condition seen in patients with autoimmune thyroid disease. Hashitoxicosis presents initially with clinical features of thyrotoxicosis and is associated with high radioiodine uptake similar to Graves' disease [24]. Later on it leads to development of hypothyroidism which is caused by lymphocytic infiltration and autoimmune destruction of thyroid gland similar to Hashimoto's thyroiditis. Anti-TSH receptor

antibodies are found in nearly 23% of patients with hashitoxicosis [25].

free T4 and free T3 are raised during the hyperthyroid phase.

It is a nonsuppurative thyroiditis caused by viral infection or as a result of post-viral illness. In twin study, some link of genetic association was also found [26]. Subacute thyroiditis is characterized by neck pain and tenderness. Initially disease presents with fever, fatigue, and myalgia along with hyperthyroidism that is followed by euthyroidism and then hypothyroidism, and lastly euthyroidism is achieved. A less or absent uptake is seen by radionuclide uptake study. Color Doppler study reveals low blood flow in the hyperthyroid phase which normalizes once euthyroidism is achieved. On laboratory study TSH remains suppressed, and

Riedel's thyroiditis is a rare condition of unknown etiology occurring in middle-aged women. In this chronic thyroiditis, thyroid follicles are replaced by fibrous tissue. Association with other autoimmune fibrosclerotic disease, i.e., retroperitoneal fibrosis and sclerosing cholangitis, is also found. Initially patients present with goiter with normal thyroid function but later on become hypothyroid. The diagnosis can be made with FNAC, but sometimes biopsy may be required for

MNG is usually detected incidentally during routine examination for evaluation of some other disease. Sometimes the patient seeks help for obvious neck swelling and cosmetic disfigurement of the neck. As MNG becomes palpable once the size is more than 1 centimeter, so large MNG mainly presents with neck swelling. Once MNG is detected, a complete history and physical examination focusing on the thyroid gland and adjacent cervical lymph nodes should be performed. Through history including history of childhood head and neck radiation therapy, total body radiation for bone marrow transplantation, exposure to ionizing radiation from fallout in childhood or adolescence, familial thyroid carcinoma, or thyroid cancer syndrome should be sought [27, 28]. Patients with long-standing MNG are more

excessive sweating, heat intolerance, and weight loss.

**3.4 Subacute (DeQuervain's) thyroiditis**

**102**

likely to have clinical features of thyrotoxicosis, and they usually present with subclinical or clinical hyperthyroidism during evaluation. The MNG may present with compressive features, i.e., dyspnea and dysphagia. Respiratory symptoms develop due to tracheal compression. Hoarseness of voice may result from compression of recurrent laryngeal nerve. Very rarely MNG may present with vocal cord palsy, but it is usually seen in malignancy. Retrosternal MNG with thoracic inlet compression can be diagnosed with Pemberton's maneuver, in which raising arm overhead causes flushing and shortness of breath due to compression of neck veins. Information regarding family members, any significant drug use, and radiation exposure should also be enquired. Thyroid examination should be done in sitting position, and during palpation information regarding thyroid shape, nodularity, tenderness, and fixity to the surrounding should be sought. Fixation to trachea, esophagus, and surrounding structure raises the possibility of malignancy. Enlarged painful and tender thyroid can be due to subacute thyroiditis or thyroid abscess. Neck mass with enlarged cervical lymph node again raises suspicion of carcinoma and warrants further evaluation.
