Thyroid Nodule

Thyroid Nodule: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Hashimoto thyroiditis

❑ Multinodular goiter

❑ Follicular adenoma

❑ Thyroid cyst

❑ Thyroid carcinoma

❑ Subacute thyroiditis

Diagnostic Approach

The major task of physical examination is the detection of nodules. A palpable nodule can be detected in 4% to 7% of adults, but these are present in approximately 50% on ultrasound. The history or physical examination should rarely dissuade one from proceeding to thyroid scan and/or fine needle aspiration.

Approximately 5% of nodules are cancer. High-risk features include: rapid growth, a very firm nodule, fixation, vocal cord paralysis, enlarged regional lymph nodes, distant metastases, and family history of medullary cancer. Moderate risk features are: Age less than 20 years or greater than 60 years, history of neck irradiation (.100 cGy .15 years before), solitary nodule, diameter greater than 4 cm, and questionable fixation.

A thyroid nodule in a hyperthyroid patient is virtually never malignant, but a prominent or hard nodule in a multinodular goiter must be evaluated for cancer.

Clinical Findings

Hashimoto thyroiditis  The gland is rubbery as a result of lymphocytic infiltration, diffusely enlarged, and bosselated. Symptoms of hypothyroidism coincide. The pyramidal lobe may be prominently enlarged.

Multinodular goiter  The gland is irregular and not as firm as in Hashimoto. Nodules may develop when colloid accumulates in hyperplastic cells (colloid cyst). Lithium, beets, and turnips are goitrogens.

Follicular adenoma  Adenoma presents as a solitary nodule that has grown slowly over years. Small adenomas are usually inactive although those larger than 3 cm may function autonomously and present with thyrotoxicosis. Reduction in size with suppressive therapy is the rule although this can also occur on occasion with thyroid cancer. Hemorrhage into a pre-existing nodule may cause acute painful enlargement.

Thyroid cyst  It transilluminates and may suddenly enlarge with pain because of hemorrhage.

Thyroid carcinoma  A firm (hardness of an unripe apple), irregular, large (>2 cm) nodule that is fixed and fails to move with swallowing suggests cancer. The consistency of the tissue may not be a reliable sign of malignancy because papillary carcinomas that have undergone cystic degeneration may present as soft nodules. Additional clues are hard cervical adenopathy, hoarseness (caused by recurrent laryngeal compression), Horner syndrome, or tenderness in a rapidly growing nodule. Anaplastic carcinoma occurs in elderly patients and has rapid local invasion. Medullary carcinoma occurs in the context of a familial MEN syndrome with pheochromocytoma.

Subacute thyroiditis  Often occurring postpartum or following an upper respiratory infection, subacute thyroiditis causes symptoms of malaise and pain over the thyroid. The thyroid is finely nodular. Acutely, there is fever, and severe, often unilateral pain, which responds readily to salicylates. The patient is usually mildly thyrotoxic.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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• Back to disease: Thyroid disorders: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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