assessment of thyroid nodule

Last edited 01/2020 and last reviewed 01/2020

Clinical evaluation of patients with thyroid nodules

NICE suggest to only consider ultrasound for adults with thyrotoxicosis if they have a palpable thyroid nodule (1)

When considering the symptomatology associated with a thyroid nodule then the onset and rate of progression of symptoms are important in terms of risk of thyroid cancer

  • persistent hoarseness and rapidly growing thyroid nodules more likely to indicate a malignant cause

Assessment of symptomatology associated with a thyroid nodule:

Possible symptoms related to thyroid nodules include:

  • a palpable neck mass
  • anterior neck pain
  • globus sensation
  • dysphagia
  • dyspnoea
  • dysphonia/ hoarseness

Swallowing complaints are common but non-specific

  • more than 50% associated with laryngopharyngeal reflux (2)

Laboratory testing

TFTs - to rule out hyperthyroidism

  • most hyperfunctioning thyroid nodules are benign


  • controversy exists about the benefit of routine measurement of serum calcitonin (2)
    • specificity of an elevated serum calcitonin (>100 pg/mL) for diagnosis of medullary thyroid cancer (MTC) is improved with pentagastrin stimulation; however, pentagastrin is no longer available in the US and supply is limited in Europe
    • some authors consider routine calcitonin measurement of uncertain benefit during initial thyroid nodule work-up (2)

Assessment of thyroid cancer risk

Need for thyroid biopsy based on clinical, laboratory, and ultrasound findings

The British Thyroid Association categories based on presence of different ultrasound features (composition, vascularity, echogenicity, shape, calcifications, lymph nodes, margins):

U1- normal Do not need biopsy, unless patient has statistically high risk of malignancy
U2 - benign Do not need biopsy, unless patient has statistically high risk of malignancy
U3 - indeterminate/equivocal Thyroid biopsy recommended
U4 - suspicious Thyroid biopsy recommended
U4 - malignant Thyroid biopsy recommended

If biopsy undertaken then next management step (whether surgical intervention or observation) based on

  • the FNA result
  • molecular markers and/or repeat FNA
  • individual patient's preferences and context


  • NICE (November 2019). Thyroid disease: assessment and management
  • Ospina NS et al. Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment.BMJ 2020;368:l667.