There are not many therapy alternatives to surgery if you have a goiter.
The large goiter may be causing obstructive symptoms, or harbor a cancer.
The obstructive component can be evaluated by MR, and pulmonary function testing, including flow loop to see if there is any upper airway obstruction. Any suspicious nodules found on ultrasound need to be biopsied.
If no obstruction or cancer is found, then alternatives are available.The most widely used is low dose Radio-iodine therapy.
In Europe and special centers, Laser has been used to shrink goiters. However, experience with this method is limited at present, although it seems promising.
Thyroid hormone is effective if the goiter responds to suppression. However, it usually dose not work on very large goiters. Ethanol Injections, PEI, are not for treatment of a whole gland, but for single cystic nodules. The best method now is Radio-iodine therapy.
A 69-year-old female with coronary artery disease, bypass surgery, and mild heart failure was noted to have a large goiter causing tracheal deviation, and symptoms of obstruction.
The MR showed mild tracheal narrowing, and the breathing test showed an abnormal flow loop consistent with upper airway obstruction due to the enlarged goiter.
The treatment of choice is surgery, but because of her heart condition, alternatives were sought. Thyroid hormone was considered dangerous with heart disease. She was referred to me for consideration for ethanol, laser, or Radio-iodine. As listed above RAI was the best alternative for her.
The goiter was visible from across the room. The trachea was deviated, and the ultrasound found two suspicious nodules in the goiter. They were biopsied and were benign colloid nodules. Thyroid blood testing was normal for TSH, T4, and Antibodies. The thyroid uptake was not elevated, but was at the lower normal range of 11% at 24 hours. Normal 8-32.
After informed consent, including all about off label use of Thyrogen, rhTSH stimulation to boost the low uptake, she was put on a low iodine diet for two weeks. The single injection of rhTSH was given, and the TSH rose to 32.