AKT · Endocrine/Thyroid

Goitre & thyroid nodule

Thyroid enlargement / discrete nodule (benign vs malignant)

Overview

Diffuse or nodular thyroid enlargement, or a discrete nodule. Most nodules are benign (colloid, cyst, adenoma) but the task is to exclude malignancy and assess function and compression. Investigated with TFTs and ultrasound, and cytology (FNA) for suspicious nodules.

Recognise

Neck swelling that moves on swallowing; may be diffuse (physiological, Graves, Hashimoto, iodine deficiency) or nodular
Compressive features: dysphagia, stridor, hoarseness (recurrent laryngeal nerve), retrosternal extension (positive Pemberton sign)
Red-flag nodule: hard, fixed, rapidly growing, with hoarseness or cervical lymphadenopathy

Red flags

Hoarseness, fixed/hard nodule, rapid growth, cervical nodes, or stridor → suspected cancer pathway / urgent
Compressive/retrosternal goitre → imaging and surgical referral

Differentials & how to tell them apart

Multinodular goitre (benign)multiple nodules, euthyroid or toxic; low malignancy risk

Thyroid cancersolitary hard fixed nodule, hoarseness, nodes, suspicious ultrasound/cytology

Thyroglossal cystmidline, moves with tongue protrusion

Graves/Hashimotodiffuse goitre with autoimmune markers

Goitre — visible thyroid enlargement
Martin Finborud / Public domain — Wikimedia Commons

Investigations

TFTs first; thyroid ULTRASOUND (U-grading) for nodules; fine-needle aspiration cytology (Thy classification) for indeterminate/suspicious; uptake scan if thyrotoxic (hot vs cold).

Management

TFTs + ultrasound ± FNA cytology; manage by function and malignancy risk

1Check TFTs and arrange ultrasound. A 'hot' (functioning) nodule on a thyrotoxic patient is rarely malignant; a non-functioning ('cold') or ultrasonically suspicious nodule needs FNA cytology.Gate: Hoarseness, a fixed/hard nodule, rapid growth or cervical lymphadenopathy → suspected-cancer pathway, not routine; compressive/retrosternal goitre → surgical assessment
2Surgery for malignancy, compression or cosmesis; manage the functional state; cytology-guided follow-up of indeterminate nodules.

Treat the functional state — levothyroxine (hypothyroid) or antithyroid/definitive (toxic)

Surgery — for compression, cosmesis, or malignancy

Key points

Most goitres/nodules are benign — but hoarseness, a hard fixed nodule, nodes or rapid growth flip it to a cancer pathway. Hot nodules are reassuring; cold/suspicious ones get FNA.

Monitor & prognosis

Ultrasound/cytology follow-up; functional status.

Mostly benign; depends on cause.

Source: NICE NG12; British Thyroid Association U/Thy grading