Hurley D L, Gharib H
Mayo Medical School, Rochester, Minnesota, USA.
Otolaryngol Clin North Am. 1996 Aug;29(4):527-40.
Nodular goiters are encountered commonly in clinical practice by primary care physicians, endocrinologists, surgeons, and otolaryngologists. Epidemiologic data suggest that in the United States, the incidence of such goiters is approximately 0.1% to 1.5% per year, translating into 250,000 new nodules annually. Nodular goiters are more common in women than in men, with advancing age, and after exposure to external irradiation. These goiters may be asymptomatic, with normal TSH levels (nontoxic), or may be associated with systemic thyrotoxic symptoms (toxic MNG or Plummer's disease). Diagnostic evaluation of patients with nodular goiters consists of clinical evaluation, biochemical testing, FNA, and imaging studies. The serum TSH level is a sensitive and reliable index of thyroid function. FNA results are pivotal to assess cancer risk in patient management for prominent palpable and suspicious nodules. Chest radiography, high-resolution ultrasonography, and computed tomography help to delineate the size and extent of a goiter in evaluating compression symptoms. Indications for treatment in patients with MNG include hyperthyroidism, local compression symptoms attributed to the goiter, cosmesis, and concern about malignancy based on FNA results. The use of levothyroxine suppression therapy to effectively decrease and control MNG size is controversial. Thyroid hormone should not be used, however, in patients with suppressed serum TSH levels, to avoid the development of toxic symptoms. Management of toxic MNG by surgery is well established. Radioiodine is also effective therapy for many of these patients. When treatment is necessary for nontoxic MNG, surgical excision is preferred. Our recommendations are as follows. For patients who have small, nontoxic multinodular goiters that are clinically asymptomatic, who are biochemically euthyroid according to serum TSH levels, and who have prominent palpable or suspicious nodules benign by FNA, yearly evaluation with serum TSH determinations and thyroid palpation is sufficient. Patients with modest but stable MNG size and normal serum TSH levels may also be managed by yearly clinical observation. In this second group, levothyroxine suppression therapy is often unsuccessful and has the potential for untoward effects from exogenous hyperthyroidism. For large nontoxic multinodular goiters with local compression symptoms, the preferred treatment is surgery. In patients with toxic MNG, treatment with either surgery or radioiodine is recommended, although patients with large goiters and large, autonomously functioning nodules become euthyroid more quickly following surgery.
在临床实践中，基层医疗医生、内分泌科医生、外科医生和耳鼻喉科医生都经常遇到结节性甲状腺肿。流行病学数据表明，在美国，此类甲状腺肿的发病率约为每年0.1%至1.5%，即每年有25万个新结节。结节性甲状腺肿在女性中比男性更常见，随着年龄增长以及在受到外部辐射后更为多发。这些甲状腺肿可能无症状，促甲状腺激素（TSH）水平正常（非毒性），也可能伴有全身性甲状腺毒症症状（毒性多结节性甲状腺肿或普卢默病）。对结节性甲状腺肿患者的诊断评估包括临床评估、生化检测、细针穿刺抽吸活检（FNA）和影像学检查。血清TSH水平是甲状腺功能的敏感且可靠指标。FNA结果对于评估可触及的明显和可疑结节患者管理中的癌症风险至关重要。胸部X线摄影、高分辨率超声检查和计算机断层扫描有助于在评估压迫症状时明确甲状腺肿的大小和范围。毒性多结节性甲状腺肿（MNG）患者的治疗指征包括甲状腺功能亢进、甲状腺肿引起的局部压迫症状、美容需求以及基于FNA结果对恶性肿瘤的担忧。使用左甲状腺素抑制疗法有效降低和控制MNG大小存在争议。然而，对于血清TSH水平受抑制的患者不应使用甲状腺激素，以避免出现毒性症状。手术治疗毒性MNG已得到充分确立。放射性碘对许多此类患者也是有效的治疗方法。对于非毒性MNG，如有必要进行治疗，首选手术切除。我们的建议如下。对于患有小的、非毒性多结节性甲状腺肿且临床无症状、根据血清TSH水平生化指标甲状腺功能正常、FNA显示可触及的明显或可疑结节为良性的患者，每年进行血清TSH测定和甲状腺触诊评估就足够了。MNG大小适中但稳定且血清TSH水平正常的患者也可通过每年的临床观察进行管理。在这第二类患者中，左甲状腺素抑制疗法通常不成功，且有因外源性甲状腺功能亢进产生不良影响的可能性。对于有局部压迫症状的大的非毒性多结节性甲状腺肿，首选治疗方法是手术。对于毒性MNG患者，建议采用手术或放射性碘治疗，不过甲状腺肿大且有大的自主功能性结节的患者手术后甲状腺功能恢复正常更快。
