Hypothesis: That changing practices in a single institution toward performing total thyroidectomy as the preferred option for the treatment of bilateral benign multinodular goiter (BMNG) can alter attitudes and practice within an entire region (Australia and New Zealand). Design:(1) Single-institution study of patients with bilateral BMNG treated by thyroidectomy over a 40-year period, examining the changing pattern of use of bilateral subtotal thyroidectomy and total thyroidectomy in the initial surgical treatment of nodular goiter. (2) Mail survey of all endocrine surgeons (n = 75) in Australia and New Zealand, seeking information on their changing practice in the surgical treatment of BMNG.Setting: Tertiary academic referral center.Patients: A group of 3468 patients who underwent thyroidectomy for bilateral BMNG during the study period. Of these, 1838 had a subtotal thyroidectomy performed and 1251 had a total thyroidectomy as the primary surgical treatment. Main Outcome Measures:The changing incidence of each type of thyroid procedure each year over the study period.Results: Within our unit, bilateral subtotal thyroidectomy was the principal procedure performed until 1984, when total thyroidectomy became the preferred procedure. Our unit now treats 94% of these patients with total thyroidectomy. Secondary thyroidectomy for recurrent goiter initially increased over the years (with a lag period of 13 years), reflecting the numbers of subtotal procedures previously performed, and is now declining. This pattern has been reflected throughout Australia and New Zealand; 60% of practicing endocrine surgeons now perform total thyroidectomy as the preferred treatment for bilateral BMNG.

Hyperparathyroidism associated with lithium may be due to either parathyroid hyperplasia or adenoma. Observations in the present study supported a true cause and effect relationship. Routine bilateral neck exploration should be performed because of a relatively high frequency of multigland involvement. However, parathyroid resection should be limited to evident disease.

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When surgery for a clinically benign single thyroid nodule is indicated, hemithyroidectomy is an adequate surgical procedure in cases where the single nodule is subsequently found to be part of a multinodular goitre. Such patients can be reassured that the chance of clinical recurrence is low. Thyroxine replacement therapy appears not to prevent recurrence.