The neck is one of the most noticeable parts of our body. Situated just below the face, it is one of the places to place one’s gaze as we chat with another person since it’s conveniently at our eye level. Unlike the rest of our body, it’s seldom covered up with clothing.

Hence, it’s no surprise that neck swellings or growths in the thyroid glands tend to be picked up early by a concerned friend or relative, or even oneself, when looking in the mirror every day. Other common sources of observer include the hairdresser and the masseur during a regular massage session. I often ask my patients with thyroid nodules how and when they were detected, and the answer not uncommonly include “my hairdresser pointed this out last week…”.

Another point of detection occurs during health screening. Many employers now provide that as part of a staff benefits package. Through this, a GP may be able to detect a thyroid swelling and confirmed through a neck ultrasound examination.

What is a multinodular goitre (MNG)?

A goitre is an enlarged thyroid gland and an MNG refers to one that has many nodules within the gland. These nodules are not normal; they are there because of an abnormal growth and therefore it is important for your thyroid doctor to distinguish a cancerous from a benign growth.

Is multinodular goitre dangerous?

Previous studies in the US have placed the risk of cancer in a single thyroid nodule to be 5%. The risk of cancer is generally thought to be smaller for an MNG. Nevertheless, your thyroid doctor will evaluate the nodules with high-resolution ultrasound and the nodules that have suspicious features will require a fine-needle aspiration biopsy (FNAB) for an analysis of the cytology.

In very rare circumstances, a person who has had a MNG for a long time may be told that a malignant transformation has taken place. This condition, known as anaplastic cancer, unfortunately carries a very poor prognosis and no curative treatment is available.

An MNG that is large and displaces vital structures in the neck may pose a problem when it compresses on the airway structures such as the larynx and trachea, or the digestive tract such as the oesophagus. Such patients may report difficulty with swallowing, a change in the voice, noisy breathing known as a stridor, or difficulty breathing when lying flat.

What should be done for a multinodular goitre?

The evaluation for any thyroid nodule includes blood tests, an ultrasound and a FNAB. The latter two tests should be repeated at fixed intervals depending on the suspicion of cancer, the rate of growth or change in characteristics of the nodules.

A FNAB is a rapid and reliable test that is conducted in the clinic. It is a simple test, relatively painless, and the results are available within a couple of days. At Thomas Ho Surgery, our specialist has been performing FNAB for over 10 years with high accuracy. He has trained junior doctors and has published the accuracy of his FNAB in the medical literature.

While the FNAB remains the diagnostic test of choice, the test relies on certain cellular features to distinguish between a cancerous and a benign growth. This limitation means that some nodules may inevitably prove indeterminate on FNAB. Moreover, this is no reliable, easy-to-administer test such as a blood cancer marker.

In this situation, a molecular test may be applied to a fine needle aspiration sample. Based on the presence of certain highly specific cancer mutations such as BRAF and RET/PTC, molecular testing can improve on the predictive analysis and probability. However, this test is expensive and not readily available in most countries.

What is the recommended treatment for multinodular goitre?

Surgery is recommended for nodules that are

  • Suspicious for malignancy
  • Enlarging at a significant rate
  • Causing compressive symptoms

For MNGs, my choice of surgery is not focused on just the few large nodules but the overall goitre and the problems it may present. Studies have shown that MNG has the tendency to regrow when partial surgery is performed. Amongst my patients, many have undergone partial surgeries in the remote past only to consult me for the emergence of a new goitre. Hence my preference and recommendation to patients with MNG is a total thyroidectomy. This ensures that the goitre problem is resolved permanently through a single safe anaesthesia and surgery. This is also supported by evidence from a population-based study I previously published from the United States.

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