Toxic Nodular Goiter or Plummer's Disease

Plummer's Disease

Toxic nodular goiter (or Plummer's Disease) is less common than Graves' disease, and its prevalence increases with age and in the presence of iodine deficiency. Disease usually progresses. With toxic nodular goiter, the medical therapy is not as helpful as with Graves' disease.

Once the diagnosis has been made, the treating physician and patient should discuss each treatment option, including logistics, benefits, expected recovery time, drawbacks, side effects, and costs.

Patients with toxic multinodular goiter or toxic solitary nodule are better treated with either I-131 therapy or thyroidectomy (per recent ATA Guidelines). Still, on some occasions, long-term, low-dose treatment with Methimazole may be appropriate.

ATA Guidelines RECOMMENDATION 41 stated that a high-volume thyroid surgeon should perform the surgery for toxic multinodular goiter.

The benefits of the surgery would include a quick recovery from the disease, absence of toxic effects from medical therapy or radioactive iodine therapy. The downside to surgical therapy would include small, 1% in a hands of experience surgeon, rate of complications and presence of a small scar. These would include 1% rate of hoarseness (injury to the vocal cord nerve), 1% low calcium level, and a 0.5% rate of bleeding or infection. In the hands of experienced thyroid surgeons, those side effects are minimal, and the scar is very small; by contrast, with a low-volume surgeon, the complication rate could approach 10%.

References:

Bahn RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, Laurberg P, McDougall IR, Montori VM, Rivkees SA, Ross DS, Sosa JA, Stan MN; American Thyroid Association; American Association of Clinical Endocrinologists.Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. 2011 May-Jun;17(3):456-520.

Stavrakis A, et al VA System, Los Angeles, Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery” Surgery. 2007 12;142(6)

Sosa JA, Udelsman R et al. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg. 9,228(3), 1998.

Pieracci FM, Fahey TJ, Cornell Univ, Effect of hospital volume of thyroidectomies on outcomes following substernal thyroidectomy. World J Surg, 5,32(5), 2008