This document outlines the investigation and management of thyroid swellings. It describes that thyroid swellings can be solitary or dominant. Evaluation involves thyroid function tests, autoantibody testing, isotope scanning, ultrasonography, FNAC, and other imaging tests if needed. FNAC is the investigation of choice to determine if a swelling is a colloid nodule, thyroiditis, or type of carcinoma. Thyroidectomy is indicated if there is a risk of neoplasia or if a swelling is malignant based on factors like age, sex, and size.

3.  Isolated or Solitary (70%): Discrete swelling in
an otherwise impalpable gland
 Dominant (30%): similar swelling in a gland
with clinical evidence of generalized
abnormality in the form of a palpable
contralateral lobe or generalized mild
nodularity

4.  Increased risk of neoplasia compared with
other thyroid swellings
Solitary
15% malignant
30-40% follicular
adenoma
Dominant
Incidence of
malignancy or
follicular
adenoma half of
that of solitary
swelling

5.  Thyroid function tests
 Autoantibody titres
 Isotope scan
 Ultrasonography
 FNAC
 Radiology
 Other scans- CT and MRI
 Laryngoscopy
 Core biopsy

6.  SerumTSH,T3 andT4
 Hyperthyroidism 
 Toxic adenoma
 Toxic Multi Nodular Goitre
Indication for isotope scanning to
localize the area(s) of hyperfunction
Combination of toxicity and nodularity

7.  To determine whether the swelling is a
manifestation of chronic lymphocytic
thyroiditis
 Presence of circulating antibodies increases
the risk of thyroid failure after Lobectomy

8. Swellings
HOT:
overactive
WARM:
active
COLD:
underactive

9.  Hot nodule: takes up isotope while
surrounding thyroid tissue does not. Here the
surrounding thyroid tissue is inactive because
the nodule is producing such high levels of
thyroid hormone thatTSH secretion is
suppressed.
 Warm nodule: takes up isotope and so does
the normal thyroid tissue around it
 Cold nodule: does not take up isotope. 80%
of discrete swellings are cold.

11.  Non invasive
 To determine physical characteristics of
swelling
Features of thyroid neoplasia
• Microcalcification
• Increased vascularity
• Macroscopic capsular breech
• Nodal involvement
Diagnostic of
malignancy

12.  “Investigation of choice”
 Excellent patient compliance
 Simple and quick
 Readily repeated

13.  Colloid nodules
 Thyroiditis
 Papillary carcinoma, Medullary
carcinoma and Anaplastic carcinoma
 Lymphoma

14.  Cannot distinguish between a benign follicular
adenoma and follicular carcinoma. Because this
distinction is dependent not on cytology but on
histological criteria, which include capsular and
vascular invasion
 False negative
 High rate of unsatisfactory aspirates (ultrasound
guided aspiration can achieve more accurate
sampling)

15.  Chest and thoracic inlet radiographs  to
confirm tracheal deviation, compression or
retrosternal extension

16.  CT and MRI
 Give excellent anatomical detail
 No role in first line of investigation
 Useful in assessing retrosternal and recurrent
swellings
 PET scan
 Useful in localizing disease which does not take up
radioiodine

17.  To determine the mobility of the vocal cords
 Usually for medicolegal reasons rather than
clinical reasons
 Presence of unilateral cord palsy + thyroid
swelling suggestive of malignancy

18.  For histological assessment
 High diagnostic accuracy but requires local
anaesthesia, and may be associated with
complications such as
 Pain
 Bleeding
 Tracheal damage
 Recurrent laryngeal nerve damage

19.  THYROIDECTOMY
 Indications:
 Risk of neoplasia (including follicular adenoma)
 Malignant swellings
 Relative indications:
 Age (in a teenager provisinally diagnosed as
carcinoma, risk increases >50 years)
 Sex (much more likely to be malignant in male)
 Size of swelling