Please note that the following is a general guideline only.
Outline
When a patient with a thyroid mass presents,
-The first step is to see if it is goitre or a thyroid nodule.
-The second step is to determine the risk of cancer within
-The third step is to see if the patient is hyperthyroid or not
-Fourth is to determine if there are compressive symptoms- if so URGENT referral
The examination should assist determine the above four features
Investigations should be directed according to the findings.
History
Is this a long-standing mass, is the whole thyroid large or a nodule?
Is it an endemic goitre
Is it a toxic goitre
Is this a nodule the patient is presenting with
Is there is a risk of cancer
Extremes in age (very young or older)
Radiation exposure
Family Hx of thyroid cancer
Hyper or Hypothyroid symptoms
Rare for a nodule to be cancerous if hyper hyperfunctioning
Are the symptoms of acute onset or a longer standing
Are there compressive symptoms
Breathing?
Swallowing? if significant URGENT referral
Examination
First confirm its the thyroid (moves with swallowing)
Determine if this is a goiter or a nodule
look for cancer
Any hard masses- Hard= risk of cancer (individual nodule or within a goitre)
Any neck nodes (nodes= cancer)
look for compressive features
if venous congestion positive Pemberton's test
Stridor-URGENT Referral
Look for hyperthyroid features
Look for hypothyroid features
Investigations
-The first line of test:TFT- Hyperthyroid
If hyperthyroid determine the cause (Graves, Toxic nodular goiter/ thyroiditis)
Endocrine review
Anti thyroid medications
-If hyperthyroid also do TC99
what we want to know is...is it a hot nodule (low risk) or a hot gland with a cold nodule (High risk of cancer)
If cold nodule need US and FNA (as below)
If Euthyroid and a nodule/ or a euthyroid goitre
US-? suspicious features in nodules (i.e. calcification etc)
if so FNA the risky nodules
Treatment Outline
If US FNA says benign- 95% it benign, need to repeat US +/- FNA in 6 months
If FNA is cancer- Total thyroidectomy plus post op radioactive I if high risk
If inconclusive / follicular cells need hemithyroid- if cancer completion total T
