1) Thyroid nodules are common findings that require evaluation to determine if they are malignant or benign. 2) Evaluation involves patient history, physical exam, laboratory tests like TSH, ultrasound of the thyroid, and fine needle aspiration biopsy of suspicious nodules. 3) Most nodules are benign but ultrasound and biopsy help determine the small percentage that require surgical removal due to cancer risk.

1. Dr. SANJAY MAHARJAN
2ND Yr Resident, ENT-HNS
MTH
APPROACH TO
THYROID NODULE

2. INTRODUCTION
• Discrete lesion within thyroid gland that is
radiologically distinct from surrounding parenchyma
• Noted by patient, or as an incidental finding
• May be
Palpable or impalpable,
Functioning or nonfunctioning

3. EPIDEMIOLOGY:
• Framingham study
Ages  35 – 59
Women  6.4 %
Men  1.5 %
• Prevalence increases with
Age
Exposure to ionizing
radiation (Nodule in
radiated patient: 35-40%
cancer)
• Pregnancy increases risk

4. • Represents a
wide spectrum
of disease
• Most are,
 Colloid nodules,
 Adenomas
 Cysts,
 Focal thyroiditis
• Only 5-6% are
malignant

6. CLINICAL ASSESSMENT: HISTORY AND
PHYSICAL EXAMINATION
• History:
• Younger and older patients (m >40yrs and F >50yrs) more
likely to have malignant thyroid nodule
• Children may present with more advanced disease
• Incidence F>M, but aggressiveness M>F
• Rapid growth of a preexisting or new thyroid nodule
(hemorrhage into cyst / carcinoma)
• Throat or neck pain (hemorrhage into benign nodule, rarely
as/w carcinoma)

7. • Compressive or invasive symptoms like
Voice change
Hoarseness
Dysphagia
Dyspnea
• Symptoms of hyperthyroidism and hypothyroidism should be
explored
• Family history
• H/o previous head and neck radiation exposure
• H/o medullary carcinoma, pheochromocytoma, or
hyperparathyroidism (MEN syndromes)

8. • Physical examination:
• Careful palpation of thyroid
(solitary or dominant nodule in
multinodular gland )
• Firm nodule  2-3 times
increased risk of carcinoma
• Substernal extension estimated
by relationship of inf aspect of
mass to clavicle
• Thoracic inlet obstruction by
Pemberton maneuver

9. • Physical findings suggesting possible malignancy include
Vocal cord paralysis
Cervical lymphadenopathy (also in Hashimoto thyroiditis,
Graves disease, or infection)
Fixation of nodule to surrounding tissues

10. INVESTIGATION
• Lab investigations :
 CBC, ESR for inflammatory or infectious thyroiditis
 TFT, Most patients are euthyroid
 TSH is an independent risk factor for predicting malignancy
 TPO antibodies in pts with high TSH (Hashimoto's
thyroiditis)
 Serum calcitonin is elevated in medullary carcinoma of
thyroid
 24-hour urine for metanephrines and catecholamines
 Serum calcium to exclude hyperparathyroidism

11. • Radiography :
 Not routinely
done
 May show
 Tracheal
deviation or
compression
 Pulmonary
metastasis
 Calcifications

12. • Ultrasound scanning :
• Noninvasive and inexpensive
• Detect non palpable nodules
• Differentiate between cystic and
solid nodules
• Identify hemiagenesis and
contralateral lobe hypertrophy
misdiagnosed as thyroid nodule
• Detect cervical nodes that may
contain early clinically occult
metastatic disease

13. • Features as/w low risk of
thyroid Ca
• Features as/w Increased risk
of thyroid Ca

17. • Computed tomography (CT) and MRI :
• Usually unnecessary
• Useful in determining
Substernal extension
Identifying cervical and mediastinal adenopathy
Evaluating relationship of thyroid lesion to adjacent neck strs
(trachea and esophagus)
• MRI is more accurate in distinguishing recurrent or
persistent thyroid tumor from postoperative fibrosis

18. • FNAC :
• Emerged in 1970s
• Procedure of choice in evaluation of thyroid nodules
• Minimally invasive
• Improved diagnostic accuracy
• Higher malignancy yield at the time of surgery
• Significant cost reductions
• Specifity : 72 – 100% , sensitivity : 65 – 98%

19. Bethesda System for Reporting Thyroid
Cytopathology

20. Respective risk of malignancy associated with each
diagnostic category (Bethesda System) is
1. Non diagnostic
2. Benign - < 1%
3. Atypia of undetermined significance/ follicular lesion of
undetermined significance (AUS/FLUS) - 5-10%
4. Follicular neoplasm/suspicious - 20-30%
5. Suspicious for malignancy - 50-75%
6. Malignant - 100%

21. • Thyroid nodule diagnostic FNA is recommended for:
A) Nodules > 1cm in greatest dimension with high suspicion
sonographic pattern
B) Nodules > 1 cm in greatest dimension with intermediate
suspicion sonographic pattern
C) Nodules > 1.5cm in greatest dimension with low suspicion
sonographic pattern
D) Nodules > 2cm in greatest dimension with very low
suspicion sonographic pattern

27. • Limitations of FNAC :
• False-positive results (difficulties in interpreting cytology)
Hashimoto thyroiditis
Graves disease
Toxic nodules
• Cannot distinguish follicular adenoma from carcinoma

29. • Thyroid scintigraphy :
• Should be performed in patients with low serum TSH
• Utilizes one of iodine radioisotopes (usu. I123) or
technetium-99m pertechnetate
• Others : Thallium-201 scan, Gallium-67, Tc-99m sestamibi
• Most benign and virtually all malignant thyroid nodules
concentrate both radioisotopes less avidly

30. • Advantage of technetium :
a. Required in smaller dose
b. Less expensive
c. Less radiation exposure
d. Shorter ½ life
• Disadvantage:
1. Only tests iodine transport (I123 also organification of I)
2. Hot nodules require I123 scanning for confirmation
3. Does not penetrate sternum - not useful in sub-sternal
extension

31. • Hyper functioning - ‘‘HOT’’
tracer uptake is greater than
surrounding thyroid (~5%
malignant)
• Iso-functioning - ‘‘WARM’’-
tracer uptake is equal to
surrounding thyroid (~10%
malignant)
• Non-functioning - ‘‘COLD ’’
uptake less than surrounding
thyroid (~20% malignant)

33. • Indeterminate :
• Superimposition of abnormal nodular tissue and normally
functioning thyroid tissue
• Should be evaluated by FNA
• Can be also be assessed by suppression scanning
Thyroid hormone sufficient to suppress TSH secretion
(2 mcg/kg for 10 days)
Second scan once TSH suppression documented
Uptake of radioiodine low or undetectable in non-
autonomous, but persist in autonomous tissue

37. RATIONAL APPROACH TO MANAGEMENT
OF A THYROID NODULE :

39. THANK YOU