In addition to features of goiter, the clinical presentation of toxic MNG includes subclinical hyperthyroidism or mild thyrotoxicosis. The pt is usually elderly and may present with atrial fibrillation or palpitations, tachycardia, nervousness, tremor, or weight loss. Recent exposure to iodine, from contrast dyes or other sources, may precipitate or exacerbate thyrotoxicosis; this may be prevented by prior administration of an antithyroid drug. The TSH level is low. T4 may be normal or minimally increased; T3 is often elevated to a greater degree than T4. Thyroid scan shows heterogeneous uptake with multiple regions of increased and decreased uptake; 24-h uptake of radioiodine may not be increased. Cold nodules in an MNG should be evaluated in the same way as solitary nodules (see below). Fine-needle aspiration (FNA) may be indicated based on sonographic patterns and size cutoffs. The cytology results, if indeterminate or suspicious, may direct the therapy to surgery. Antithyroid drugs, often in combination with beta blockers, can normalize thyroid function and improve clinical features of thyrotoxicosis but do not induce remission. A trial of radioiodine should be considered before subjecting pts, many of whom are elderly, to surgery. Subtotal thyroidectomy provides definitive treatment of goiter and thyrotoxicosis. Pts should be rendered euthyroid with antithyroid drugs before surgical intervention.

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