Most thyroid lumps are benign but 5% are malignant and it is important to distinguish this sinister minority.
Benign thyroid lumps may include:
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- Between 5-7 % of adults have thyroid lumps.
- 95% are benign.
- Thyroid nodules are uncommon (approximately 1.5%) of children and adolescents.
- Lumps are more common in areas of low iodine consumption. The incidence of malignancy in these lumps rises from 5% to as high as 40%.
- Malignancy is more common where benign thyroid disease has existed.
- The risk of malignancy rises with age.
- Thyroid cancers are more common after exposure to radiation.
Red flag features
- Family history of thyroid cancer.
- History of previous irradiation or exposure to high environmental radiation.
- Child with a thyroid nodule.
- Unexplained hoarseness or stridor associated with goitre.
- Painless thyroid mass enlarging rapidly over a period of a few weeks.
- Palpable cervical lymphadenopathy.
- Insidious or persistent pain lasting for several weeks.
- Thyroid lumps are often asymptomatic and are noticed by family members or seen in the mirror.
- They may sometimes cause pain and rarely present with features of compression of the trachea.
- Ask about previous radiation.
- Ask the patient to drink some water and note the thyroid move as she/he swallows.
- Note enlargement or asymmetry.
- Stand behind a seated patient and use the 2nd and 3rd fingers of both hands to examine the gland as she/he swallows again.
- Note lumps, asymmetry, size and tenderness.
- Check for regional lymphadenopathy.
- Non-toxic goitre - non-functioning nodules.
- Toxic nodular goitre - functioning nodules.
- Graves' disease - diffuse overactive thyroid gland.
- Hashimoto's disease - autoimmune destruction of the gland.
- Solitary thyroid nodule - 15-25% are cysts and can be aspirated.
- Thyroid carcinoma.
- Medullary cell carcinoma.
- Thyroid lymphoma - usually non-Hodgkin's.
- De Quervain's thyroiditis - neck pain, fever and lethargy soon after an upper respiratory infection or a viral illness.
- Acute suppurative thyroiditis - results from bacterial or fungal infection causing abscess.
- Perform TFTs. (Most will be euthyroid - refer those which are abnormal for endocrine opinion.)
- Ultrasound (US) is useful to detect and characterise most thyroid nodules. It can show cystic lesions 2 mm wide and solid lesions 3 mm wide. Ultrasound examination is far more sensitive than clinical examination and only 4-7% of nodules detected by US are clinically palpable.
- Fine-needle aspiration (FNA) gives tissue for cytology. It is performed under US guidance (for maximum accuracy) but for palpable nodules it can be performed with palpation. It is safe, inexpensive and provides direct information.
FNA is best for uninodular lesions. Sensitivity is near 80% with specificity approaching 100%. False-negative and false-positive results occur in less than 6%. FNA is the first and, in the vast majority of cases after US, the only test required for the evaluation of a solitary thyroid nodule.
- Radionuclide imaging looks at iodine uptake by the thyroid:
- Normal is called 'warm'.
- Lesions that take up excessive amounts of iodine are called 'hot' - 4% of hot nodules contain tumour.
- Lesions that do not take up iodine are called 'cold' - 16% of cold nodules contain tumour.
Low 123 I uptake in a single palpable nodule gives a risk of malignancy of 10-25%, falling to 1-3% if multiple nodules are demonstrated on the scan.
- CT scans and MRI scans are valuable to detect local and mediastinal spread and regional lymph nodes.
Further reading & references
- Kelley DJ; Thyroid, Evaluation of Solitary Thyroid Nodule, Medscape, Dec 2011
- Thyroid Nodules, endocrineweb
- Mehanna HM, Jain A, Morton RP, et al; Investigating the thyroid nodule. BMJ. 2009 Mar 13;338:b733. doi: 10.1136/bmj.b733.
- Turkington JR, Paterson A, Sweeney LE, et al; Neck masses in children. Br J Radiol. 2005 Jan;78(925):75-85.
- Schwetschenau E, Kelley DJ; The adult neck mass. Am Fam Physician. 2002 Sep 1;66(5):831-8.
- Neck lump, Prodigy (February 2010)
- Rosenberg TL, Brown JJ, Jefferson GD; Evaluating the adult patient with a neck mass. Med Clin North Am. 2010 Sep;94(5):1017-29.
- Guidelines for the management of thyroid cancer, British Thyroid Association and Royal College of Physicians (2007)
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 20/02/2012||Document ID: 2870 Version: 22||© EMIS|
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