A thyroid nodule is a lump inside the thyroid gland, very common and often found on exam or by chance on imaging. Most are benign, so the work-up aims to find the few that are cancer or that make too much hormone.
Key symptoms
- Painless lump in the front of the neck, often found by chance
- Feeling of pressure or a lump when swallowing
- Hoarse voice or trouble swallowing or breathing if large
- Symptoms of an overactive thyroid if the nodule makes hormone
- Often no symptoms at all
What you find on exam
- Palpate the thyroid; note size, firmness and whether it moves on swallowing
- Hard, fixed or fast-growing nodule raises concern
- Neck lymph nodes for enlargement
- Voice quality and signs of tracheal shift
- Signs of thyroid over- or underactivity: pulse, tremor, skin, reflexes
Tests
- TSH first for every nodule
- Thyroid ultrasound: size and suspicious features such as microcalcifications or irregular margins
- Radioiodine uptake scan if TSH is low; a hot nodule is rarely cancer
- Fine-needle aspiration based on ultrasound pattern and size, reported with the Bethesda system
Treatment basics
- Benign nodule: follow-up ultrasound and clinical review
- Suspicious or malignant cytology: surgery (lobectomy or total thyroidectomy)
- Toxic nodule: radioactive iodine or surgery, with methimazole as a bridge
- Large benign nodule pressing on the neck: surgery or ablation in selected cases
Red flags
- Rapid growth, a hard fixed mass or enlarged neck nodes
- New hoarseness, stridor or trouble swallowing
- Past head and neck radiation or family history of thyroid cancer
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.