Diagnosis/Definition
- Approximately 4-7% of the population has a palpable thyroid nodule found on physical examination.
- Due to the increase in neck imaging with various modalities, many non-palpable nodules are being discovered.
- Most thyroid nodules are benign and can be treated conservatively with suppression, observation or aspiration of simple cystic lesions.
- Thyroid nodules can be cystic, solid or mixed.
- Solid lesions are malignant in approximately 21% while cystic and mixed lesions are malignant in 7% and 12% respectively.
Initial Diagnosis and Management
- History: Thyroid nodules can be found in patients of any age. The age of the patient and the sex are relevant factors in determining risk of malignancy. The history should evaluate for symptoms of hypo or hyperthyroidism. Other important historical facts include voice changes, dysphagia, aspiration symptoms, cachexia, weight loss, prior history of radiation therapy, and failure of suppression therapy.
- Physical Examination: The physical exam should focus on the thyroid gland and the surrounding lymph nodes. The overall size and consistency of the gland as well as the number and size of the thyroid nodules should be evaluated. A thorough examination of the neck for evidence of cervical lymphadenopathy should be performed.
- Ancillary Tests: TSH and an ultrasound for non-palpable nodules.
Ongoing Management and Objectives
- Thyroid nodules require evaluation to determine the potential for malignancy.
- The nodules that are confirmed to be malignant or indeterminate lesions require surgical resection.
Indications for Specialty Care Referral
- Thyroid nodules over 10 mm in diameter or with concerning findings on imaging should be referred to ENT, General Surgery or Endocrinology for fine needle aspiration.
- Thyroid nodules that have grown significantly in size should be referred.
- Nuclear medicine thyroid scans are NOT indicated to evaluate a nodule, unless the patient is hyperthyroid.
- An large thyroid gland from goiter or large nodule suspected of causing airway compression or dysphagia should be referred.
- A hyperthyroid patient with a hot nodule (autonomous, “toxic”) may be cured by thyroid lobectomy and should be referred.
Criteria for Return to Primary Care
The patient will be followed by the respective specialty care clinic until the nodule has been treated surgically and the patient is recovered or until the nodule is determined to be benign.
