Synopsis
Assess diffuse enlargement and focal nodules systematically, separate airway and cancer risk from thyroid function, and route ultrasound, scintigraphy and cytology through current UK pathways.
- Goitre means thyroid enlargement and can be diffuse or nodular, euthyroid, hypothyroid or hyperthyroid; structure and function must be assessed separately.
- Most thyroid nodules are benign, but history, examination and structured ultrasound determine which need cytology or specialist surveillance.
- Ask about growth rate, pain, dysphagia, dyspnoea, positional symptoms, voice change, radiation exposure, family syndromes and previous thyroid disease.
- Examine size, consistency, mobility, retrosternal signs, tracheal position, cervical nodes and voice; stridor or Pemberton-type congestion requires urgent escalation.
- Measure TSH before or alongside ultrasound because a suppressed result directs functional scintigraphy and changes whether a nodule should be aspirated.
- Ultrasound should report both lobes, nodule size and features, cervical nodes and a recognised local risk category, not simply describe a nodule as present.
- Fine-needle aspiration is the first pathological test for an indicated nodule; size thresholds depend on ultrasound risk, clinical context and current local multidisciplinary guidance.
- A scintigraphically hot autonomous nodule is rarely malignant and generally does not need routine FNA unless a separate suspicious feature exists.
- CT of neck and chest helps define retrosternal extension or tracheal compression, but iodinated contrast requires thought when hyperthyroidism or radioiodine treatment is relevant.
- Normal TSH does not rule out thyroid cancer, and abnormal TSH does not prove a nodule is malignant; avoid collapsing two different questions into one.
Key red flags
Rapid or progressive growth, hard fixation, suspicious cervical nodes, persistent unexplained hoarseness, prior neck irradiation or a relevant familial syndrome should accelerate specialist and cancer-pathway assessment.
Stridor, orthopnoea, positional dyspnoea, dysphagia, facial plethora or venous distension on arm elevation suggests tracheal, oesophageal or thoracic inlet compromise and may require emergency care.
Sudden pain and enlargement may represent haemorrhage into a cyst or nodule, while fever and focal inflammatory signs raise abscess; airway effect determines urgency.
Investigation priorities
Determine whether the structural lesion is euthyroid, hypoactive or autonomous.
Management branches
Stridor, rapid expansion, positional respiratory compromise or venous congestion is present.
- Keep the patient in the safest tolerated position, assess ABCDE and summon senior anaesthesia and ENT before airway deterioration makes intervention more difficult.
- Use urgent cross-sectional imaging only when the airway is sufficiently stable, with endoscopic assessment and critical-care monitoring directed by the specialist team.
- Plan definitive decompression, drainage or thyroid surgery according to cause; do not send a threatened airway through a routine outpatient ultrasound route.