If the enlargement of the gland is moderate, there are no symptoms and serum TSH is normal, therapy is not required. If there are symptoms due to pressure, if the patient is disturbed by the appearance of the goiter, if there is growth of one nodule, or possible toxicity develops, diagnostic measures and treatment are necessary. Attempts to reduce multinodular goiter by administering suppressive doses of thyroid hormone are usually little or not effective and carry the risk of inducing thyrotoxicosis if autonomy of thyroid function is already present. Although this form of treatment is still being used by about half of the clinicians in the USA and Europe 76,76a, it is the opinion of this author that it is obsolete and dangerous for the elderly. However other physicians believe that thyroid hormone replacement in a dosage that does not induce hyperthyroidism can be used without difficulty, and may help prevent growth of a goiter over years.

Administration of 131I in euthyroid or hyperthyroid multinodular goiter, to both decrease the size and to treat thyrotoxicosis is becoming more popular over the years because of its efficacy and safety, especially in Europe.80-84 A substantial reduction in goiter size after one or more treatment doses, though not always complete, occurs in virtually all patients.85 85a Hypothyroidism ensues in a substantial number of patients, varying from 25 percent after five years85,86 to 100 percent after eight years83 depending on the cumulative 131I dose administered and the sensitivity of the thyroid to 131I. After administering large doses of 131I, temporary increases of thyroid hormone levels may complicate the clinical situation.87 In the anticipation of such situations, administration of antithyroid drugs for several weeks before administration of 131I and/or treatment with beta adrenergic blocking agents after 131I administration should be considered. Also multiple small doses of 5-10 mCi 131I (185-370 MBq) may be administered. A very interesting side effect of this treatment, as noted below, is the induction of Graves' Disease in 5-10 percent of patients. This is presumed to be due to release of antigens, stimulating an immune response.

Even in the case of large goiters, causing substantial tracheal compression with concomitant airflow obstruction treatment with radioactive iodine can be very effective.87a,87b.Huysmans et al.87a, treated 19 elderly patients (mean age 66.14 years) with a multinodular goiter with a mean thyroid volume of 296ml (range 108-1002 ml),with a single intravenous dose of 131I,aimed at delivering 3.7Mbq/g thyroid tissue. No exacerbation of compressive symptoms occurred. A mean percent of reduction in thyroid volume of 43% was noted after one year. After administering the same dose 131I to patients with toxic- or nontoxic multinodular goiter, without substernal extension, no increase in thyroid volume was seen immediately after treatment.87c If felt necessary small multiple doses may be given. It is the opinion of this author and of others 87d that in general radioactive treatment of euthyroid- or toxic MNG is the first choice of treatment. Prior administration of human recombinant TSH may reduce the dose RAI to be given 87da.  Stimulation with rhTSH before (131)I therapy not only hinders the decrease in the thyroid RAIU observed with conventional (131)I therapy but in fact also significantly enhances the absorbed thyroid dose ( total change average + 74%). Whether this leads to a significant increase in goiter size reduction needs additional study87db. 

Many physicians, especially in the United States, consider subtotal thyroidectomy to be an useful alternative therapy 76, especially if a well qualified surgeon is available. Surgery offers a rapid reduction in goiter with minimal risk, provides an histologic diagnosis, typically leaves no mass, and of course provides no radiation exposure. Explorative surgery should be performed in case of sudden growth of the goiter, bleeding leading to mechanical symptoms, when a firm nodule is present, suspicious enlarged lymph nodes are palpable, vocal cord paralysis is found, or in some cases when there is substernal extension of the goiter causing substantial trachea obstruction. The author believes that surgery is otherwise hardly needed, except possibly in younger patients when the dose of radioiodine to be given is high.84 The authors do not endorse prophylactic surgery to prevent the occurrence of carcinoma.

After surgical removal of a nodular goiter, it seems theoretically sound to give the patient minimally replacement or suppressive doses of thyroid hormone to suppress TSH production and prevent regeneration of the goiter. However this form of therapy is controversial. Although in one report no recurrences were found during thyroid hormone administration 87e, in more recent studies others found no difference between untreated and patients treated with thyroid hormone after operation 87f,g,h. In one of these studies 87h carried out over 9 years, no effect of T4 treatment after thyroidectomy was seen in 104 patients operated for non-toxic goiter (the recurrence rate was 9.5% with treatment compared with 11.3% in untreated patients). If re-growth occurs, early ablative treatment with 131I should be considered.

There is no place for administration of iodide in sporadic multinodular goiter. It generally has little or no beneficial therapeutic effect, and in an occasional patient may be followed by a rise in plasma hormone concentration and symptoms of thyrotoxicosis.49,88 This condition is the "jodbasedow" phenomenon, and is dependent on autonomy of function of some elements of the goiter. Its occurrence is not confined to regions of iodine deficiency and is seen on occasion wherever iodide is administered to patients with well-established multinodular goiter. This should be remembered when elderly patients, that may have MNG, are given radiographic contrast agents for IVP, CAT or other studies.

Multinodular goiters frequently recur after partial thyroidectomy. Solymosi and Gal reported their experience in treating such recurrent nodular goiters with percutaneous ethanol injections. Patients had on average three sessions with injections, with a total dose of around 0.88 ml of ethanol per ml of nodular volume, and their experience was that nodules shrank by more than 50% of the pretreatment volume. Some patients experienced burning pain, and one had temporary hoarseness. They believe this is an appropriate therapy for recurrent nodular goiter (88.1).