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Thyroid nodules

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🧠 Introduction

A thyroid nodule is a discrete lesion within the thyroid gland, radiologically distinct from surrounding parenchyma. Nodules are common (especially in women & elderly) → most benign 👍 but a minority are malignant (red flag 🚨). Hence, careful risk stratification + appropriate investigation is essential.

📊 Epidemiology

👵 Prevalence ↑ with age → 50–60% of people >60y have nodules on US.
♀:♂ ≈ 4:1 → but ♂ nodules more likely malignant.
Palpable nodules in ~4–7% adults → most incidental findings on imaging.

🩺 Clinical Presentation

😌 Asymptomatic: Most found incidentally.
👀 Neck lump: Moves with swallowing.
😮‍💨 Compression: Dysphagia, dyspnoea, hoarseness (recurrent laryngeal nerve).
⚡ Thyroid dysfunction: Usually euthyroid, but may present with hyper- or hypothyroidism.
🔥 Pain: May indicate haemorrhage into a cyst or aggressive growth.

🚨 Risk Factors for Malignancy

👶 Age extremes: <20 or >70 yrs.
♂ Gender: Malignancy risk relatively higher in men.
☢️ Radiation exposure: Childhood irradiation = highest risk.
👨‍👩‍👧 Family history: MEN2, thyroid cancer.
⚡ Red flags: Rapid growth, hard/fixed nodule, vocal cord palsy, cervical lymphadenopathy.
😮‍💨 Compression symptoms: Dysphagia, dyspnoea.

🔍 Differential Diagnosis

Benign: Colloid nodules, cysts, follicular adenoma, Hashimoto’s thyroiditis, subacute thyroiditis.
Malignant: Papillary carcinoma (80%), Follicular carcinoma, Medullary carcinoma (MEN2), Anaplastic carcinoma (aggressive, elderly), Thyroid lymphoma.
Other: Iodine deficiency goitre, pregnancy-related nodularity, metastatic disease (rare).

📊 Causes & Management of Thyroid Nodules

Cause	Features	Investigations	Management
🪢 Benign Colloid Nodule	Most common; smooth, soft, mobile nodule; euthyroid	USS: cystic/solid, regular margins; FNA benign	Reassure; monitor with USS; surgery only if symptomatic (large/goitre)
🔥 Toxic Adenoma (“Hot Nodule”)	Solitary autonomous hyperfunctioning nodule; thyrotoxicosis	RAI uptake: focal “hot spot”; suppressed TSH	Radioiodine ablation OR surgical lobectomy; β-blockers for symptom control
🌸 Multinodular Goitre	Multiple nodules; common in elderly, iodine deficiency	USS: multiple nodules; RAI uptake: patchy; TFTs may show thyrotoxicosis	Radioiodine or surgery if compressive symptoms; carbimazole if thyrotoxic
🎗️ Thyroid Cancer (Papillary, Follicular, Medullary, Anaplastic)	Hard, irregular, fixed nodule; cervical lymphadenopathy; hoarseness	USS: hypoechoic, microcalcifications, irregular margins; FNA cytology (Bethesda classification)	Total/hemithyroidectomy ± radioiodine (depending on type/stage); lifelong thyroxine suppression
🧪 Thyroiditis (e.g. Subacute, Hashimoto’s)	Tender or “rubbery” firm thyroid; may fluctuate between hyper- & hypothyroidism	↑ ESR/CRP in subacute; +anti-TPO Abs in Hashimoto’s	NSAIDs/steroids for pain (subacute); levothyroxine if hypothyroid
💊 Cystic Lesions (Thyroid cyst, haemorrhage)	Sudden onset swelling; may be fluctuant or tender	USS: cystic lesion; aspiration diagnostic & therapeutic	Aspiration; surgery if recurrent or suspicious

🧪 Investigations

🧍 History & exam: Risk factors, cervical LN assessment.
🧪 Bloods: TSH, free T4/T3, ± thyroid antibodies, ± calcitonin (if medullary Ca suspected).
🖥 Ultrasound (US): First-line; assess echogenicity, margins, calcifications, vascularity → classify with TI-RADS.
☢️ Radioisotope scan: “Hot” nodule = benign, “Cold” = ↑ risk (but most still benign). Only done if TSH low.
🧬 FNA (Fine Needle Aspiration): Gold standard cytology → Bethesda system reporting.
🧪 Molecular tests: For indeterminate cytology (e.g., BRAF, RAS mutations).
📷 CT/MRI: Large goitre, retrosternal extension, or compressive symptoms.
👄 Laryngoscopy: If hoarseness or vocal cord palsy suspected.

⚕️ Management

✅ Benign nodules: Observe + serial US; surgery only if compressive/cosmetic/growth.
🚨 Suspicious/malignant nodules: Surgery (hemi- or total thyroidectomy) ± radioactive iodine, ± TSH suppression with thyroxine.
❓ Indeterminate cytology: Repeat FNA / molecular testing / diagnostic lobectomy.
🔥 Autonomous (“hot”) nodules: Radioiodine ablation, surgery, or antithyroid drugs if hyperthyroid.

📅 Follow-Up

🔁 Regular US + exam for benign nodules.
🧪 TFT monitoring for thyroid function.
🎯 Thyroid cancer: long-term follow-up with thyroglobulin levels ± imaging for recurrence.

📌 Conclusion

Thyroid nodules are common and mostly benign, but malignancy must always be excluded. 🧪 Risk stratification relies on a combination of clinical features + ultrasound + FNA cytology. Most thyroid cancers (esp. papillary) have an excellent prognosis if diagnosed early and treated appropriately.

📚 References

Haugen BR et al. 2015 ATA Guidelines for Thyroid Nodules & Differentiated Cancer. Thyroid. 2016.
Gharib H et al. AACE/AME/ETA guidelines for management of thyroid nodules. Endocr Pract. 2016.
Cibas ES, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology. Am J Clin Pathol. 2009.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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