Multinodular goitre

Nodular thyroid swelling which may be associated with hyperthyroidism, and is not auto-immune in origin. The diagnosis is usually made clinically, though an ultrasound scan and thyroid function testing are often performed as part of the assessment.

Has there been any obvious neck swelling or pain? 

Painful diffuse neck swelling is suggestive of thyroiditis which can cause acute thyrotoxicosis.

Discomfort from a diffusely enlarged gland is more common with Graves' thyrotoxicosis.

Painless, long standing nodularity of the neck is more suggestive of a multinodular goitre, and a single nodule suggests a follicular adenoma as the cause of thyrotoxicosis.

Sudden swelling is most common with a cyst, which is not usually associated with thyroid overactivity. Sudden painful swelling suggests a bleed into an existing nodule.

A short history of thyroid swelling should alert to the possibility of thyroid cancer and demands ultra-sound and fine needle aspiration assessment, though this is not typical with thyrotoxicosis.

Long standing painless thyroid swelling, with some fluctuation in size is more likely to represent a multinodular goitre.

Who first noticed the change in their neck?

Often family members will report that the swelling is long standing though the patient may only recently have noticed it, for example when a necklace or collar has become tight.

Has the neck swelling appeared gradually or has there been any sudden change in the neck?

Long standing gradual increase in the size of the thyroid, with some fluctuation is typical of a multinodular goitre. Sudden changes or rapid growth require urgent assessment.

Has there been any pain or tenderness in the neck?

Sudden painful swelling may indicate a bleed into a thyroid nodule or cyst. Diffuse painful swelling is more indicative of thyroiditis.

Has there been any change in the patient's voice?

Long standing hoarseness may occur with hypothyroidism. However, a new change should always alert to the possibility of thyroid cancer, particularly anaplastic thyroid cancer, and requires urgent assessment.

Do they have difficulty swallowing?

Document a history of dysphagia carefully. Many patients with an enlarged thyroid of any cause may complain of symptoms like this, with increased awareness of their neck and as they swallow. Actual dysphagia i.e difficulty swallowing certain foods or fluids, a feeling that food actually gets stuck, or the need to drink copious fluids to help wash solids down, requires urgent assessment. This may occur with a large or retrosternal multinodular goitre, but may also indicate malignancy, particularly if it is of recent or rapid onset.

Has the patient developed noisy breathing, started to snore, or finds it difficult to breathe in certain positions?

These indicate incipient stridor and require urgent assessment.

How are they affected personally by their neck swelling?

The management of a patient who is asymptomatic may be quite different to that of someone who is in pain, embarrassed or upset by the swelling, or worried that this may be cancer.

Has the patient noticed any other lumps or bumps or changes in their neck?

Lymphadenopathy in the neck or elsewhere is highly suspicious for a malignancy rather than multinodular goitre. Changes in the shape of the neck on swallowing, or on protruding the tongue suggests alternative pathologies.

Is there any family history of thyroid swelling or neck surgery?

Thyroid cancer, multinodular goitres and auto-immune thyroid disease may all occur more frequently within family members.

Where is the family from originally?

Multinodular goitre and endemic goitres are particularly common in certain geographical regions with iodine deficiency.

Has the patient lost or gained any weight unintentionally? 

Many patients with hyperthyroidism will lose weight due to increased metabolic rate, though some will gain it due to increased appetite.

Has their appetite increased? 

Increased appetite with weight loss is a classic presentation of hyperthyroidism.

Does the patient complain of diarrhoea or a change in bowel habit? 

Increased passage of stools and diarrhoea may occur with any cause of hyperthyroidism. Coeliac disease may also be associated with auto-immune thyroid disease, rather than multinodular disease. This may also present with a change in bowel habit and weight loss.

Do they feel anxious or more irritable than usual? 

Anxiety and irritability are common features of thyrotoxicosis of any cause.

Has the patient noticed a change in their energy? 

Many patients with hyperthyroidism have an abundance of energy, though some are unable to relax, and so also feel tired.

Others may have apathetic thyrotoxicosis in which their energy is paradoxically low.

Is the patient sleeping normally or are they more tired than usual? 

Many patients with hyperthyroidism will be unable to sleep well as they cannot relax despite feeling physically exhausted.

Has there been a change in menstrual cycle? 

Oligomenorrhoea, scanty periods and amenorrhoea may all occur.

Does the patient feel hot or flushed?

Heat intolerance is typical with hyperthyroidism.

Premature ovarian failure may be associated with auto-immune thyroid disease and may also present with oligomenorrhoea and flushes.

Does the patient feel tremulous or have they developed an overt shake? 

Tremor is common with thyrotoxicosis of any cause.

Does the patient complain of any changes to their skin or hair? 

Some patients develop itchy skin with thyrotoxicosis. Generalised alopecia may also occur.

Has the patient developed any cardiac or respiratory symptoms? 

Palpitations, or a feeling of a racing or irregular heart beat, are suggestive of a tachycardia or arrhythmias. Exertional chest pain suggests cardiac ischaemia. Breathlessness or swollen ankles might suggest thyrotoxic cardiomyopathy, or pulmonary embolism.

Is there any chance the patient could be pregnant? 

The symptoms of thyrotoxicosis may mimic those of pregnancy.

Early foetal loss or miscarriage is more common in women with thyrotoxicosis.

Pregnancy may also cause transient thyrotoxicosis due to stimulation of the TSH receptor by high hCG levels.

Radioactive iodine is absolutely contraindicated in pregnant women.

Has there been any recent intercurrent illness, for example a viral respiratory tract infection?

Thyroiditis typically follows a viral illness, though this is frequently unrecognised.

Has the patient noticed any changes in their eyes?

Ask specifically whether their eyes have been feeling gritty or dry, as though there is something stuck in them. Ask whether they have looked red or puffy at times, or whether their appearance has changed. Also ask whether they have developed double vision in certain directions or when tired. Any of these symptoms suggests that Graves' disease is the underlying cause of thyrotoxicosis.

A startled appearance, with slightly wider eyes than usual, may occur with any cause of thyrotoxicosis.

Does the patient smoke?

Smoking increases the risk and severity of ophthalmopathy.

Is there any family or personal history of thyroid dysfunction, pernicious anaemia, vitiligo, Addison's disease, alopecia, diabetes or celiac disease?

Any of these may be associated with auto-immune, rather than multinodular, thyroid dysfunction.