Multinodular goitre (MNG) is characterized by the growth of multiple nodules within the thyroid gland that are structurally and functionally altered. It develops through stages of thyroid hyperplasia and hypertrophy followed by fluctuations in TSH levels which promote the formation of inactive nodules within areas of active and inactive thyroid tissue. MNG most commonly affects middle-aged females and presents as a slowly progressive disease with multiple, firm nodules of varying sizes within the thyroid gland. While often benign, MNG can potentially lead to complications such as hyperthyroidism, thyroid cancer, or tracheal obstruction.

1. MULTINODULAR GOITRE
ANAKHA RAJENDRAN
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4.  MNG is a discordant growth with functionally and structurally altered thyroid
follicles presenting as multiple nodules in thyroid.
 It maybe due to fluctuation in TSH level; other causes include iodine deficiency,
goitrogens, hereditary, dyshormonogenesis.

5. STAGES OF MNG FORMATION
 Stage of hyperplasia and hypertrophy
 Stage of fluctuation in TSH
 Stage of formation of nodules.inactive

6. PATHOGENESIS
 Persistent TSH stimulation
 Diffuse hyperplasia of gland ..all active lobules and uniform iodine intake
 When there is Fluctuation of TSH level
 Mixed areas of active and inactive lobules develop due to Increased sensitivity of
follicular cells to TSH
 Active lobules become more vascular and hyperplastic
 Haemorrhages causes central necrosis leaving a rim of active follicles
 Necrotic lobules coalesce .Nodule formation filled with colloid
 Internodular tissue is active
 Many nodules formed -> MNG

7. C/F
 More common in middle age females
 Slowly progressive disease
 Multiple nodules of different sizes
 Firm, nodular, non tender, moves with deglutition
 Recent increase in size signifies malignant transformation or haemorrhage.
 Positive Kocher’s test is due to compression of trachea (tracheomalacia /scabbard’s
trachea) in long standing MNG.
 Nodule when calcified becomes harder; necrosis softens the nodule.
 Carotid infiltration
 Pembertons Sign

9. COMPLICATIONS
 Secondary thyrotoxicosis(30%)
 Follicular carcinoma of thyroid(10%)
 Haemorrhage in a nodule
 Tracheal obstruction, calcification
 Cosmetic problem

10. INVESTIGATIONS
 T3, T4, TSH, US neck, FNAC. (Dominant)
 XRAY neck- ring calcification, position and compression of trachea
 Indirect laryngoscopy- vocal cords; occult RLN palsy
 Radioisotope iodine scan
 Routine blood investigations, serum calcium
 CT scan/ MRI – retrosternal extension

13. TREATMENT
 Surgery preferred – irreversible, complications, cosmetic
 Total thyroidectomy is preferred
 Subtotal thyroidectomy (8g)
 Partial thyroidectomy/ Hartley Dunhill operation
 Post operative L- thyroxine (fluctuation; recurrence)
 Prevention- 0.1-0.2mg L- thyroxine, iodine- rich diet, iodized salts,avoid
goitrogenic diet and drugs

14. THANK YOU