The multinodular goiter is associated with the complications of malignant disease and hyperthyroidism. The important indications for surgery include large glands that may or may not be toxic and those with a hard or tender dominant nodule or with the signs suspicious of cancer including hardness, fixation, pressure symptoms, enlarged satellite lymph nodes, and lack of improvement on thyroid therapy. Thyroid scans are helpful when positive but useless if equivocal. Selection of patients for observation, or substitution therapy, or operation, must rest upon these individual considerations.
Welch CE. Therapy for Multinodular Goiter. JAMA. 1966;195(5):339-341. doi:10.1001/jama.1966.03100050047016