24 y/o male non-smoker, w/ no significant PMHx presents to ED with ℅ throat pain x 2 months. Pt states the throat pain is 8/10, constant, does not radiate, and has been getting worse over the past few days. He has been taking OTC Aleve for the pain with minimal relief. Pt is also experiencing odynophagia, fatigue and changes in his voice. He states “I have to speak much louder to get my voice out”. He also admits to wt loss in the past month ( can not quantify amount of weight loss, but states his pants are too loose). Pt is currently here on vacation from Gayana x 3 week.  Denies any SOB, fever, chills, night sweats, palpitations, coughing, voice hoarseness, drooling, ear pain, jaw pain, neck pain, abdominal complaints, or sick contacts.

During the patient’s workup the CT scan of the neck and soft tissue showed mixed/low attenuation within the left and right lobes of the thyroid gland raising suspicion of a multinodular goiter.

The article I chose for the management of this patient was a review article of, which attempts to summarize the best approach and management of thyroid nodules. Their main goal was to help provide guidance to the clinician decision making process.

According to this article:

• Thyroid nodule are most likely discovered during physical examination or incidentally during various imaging procedures.
• The initial evaluation should always include a history and physical examination focusing on features suggestive of malignancy.
• Serum thyrotropin (TSH) and thyroid ultrasonography (US) are pivotal in the evaluation of thyroid nodules, as they provide important information regarding thyroid nodule functionality and the presence of features suspicious for malignancy.
• Ultrasound guided Fine needle aspiration (FNA) biopsy is the most accurate and reliable tool for diagnosing thyroid malignancy and selecting candidates for surgery.
• FNA based on an adequate sample is 95% accurate for diagnosing thyroid cancer
• Surgery is strongly recommended for solid nodules and close observation or surgery for partially cystic lesions, as they may harbor neoplastic potential.
• Surgery, with lobectomy or total thyroidectomy is the treatment of choice for malignant and suspicious lesions
• Current management for most patients with indeterminate cytology at FNA biopsy consists of diagnostic surgery to establish a histopathological diagnosis
• T4 suppressive therapy is controversial: it is associated with the risks of iatrogenic hyperthyroidism, but may prevent new nodule formation
• Most benign thyroid nodules do not require any specific intervention, unless there are local compressive symptoms from significant enlargement, such as dysphagia, choking, shortness of breath, hoarseness, or pain, in which case thyroidectomy should be performed.

Important points on Thyroid Ultrasound:

• Thyroid US allows targeting of nodules with suspicious appearance for biopsy by providing information on nodule dimensions, structure, and thyroid parenchymal changes.
• US features that have been found to be indicative of malignant potential.
• Features include microcalcifications(31.6% likelihood of malignancy), irregular or microlobulated margins, hypoechogenicity, taller- than-wide shape, and increased intranodular vascularity.
• A combination of at least 2 of these characteristics succeeds in pointing out a subset of lesions at high risk.
• US findings such as isoechogenicity and spongiform appearance (defined as aggregations of multiple microcysts in more than 50% of the nodule) are features highly suggestive of benignity. The number of nodules and their size are not predictive of malignancy.

Number of nodules and nodular size:

• Nodules smaller than 1 cm is as likely as a larger nodule to harbor neoplastic cells in the presence of suspicious US features.
• Choosing an arbitrary size as cutoff for the likelihood of cancer or stratifying the risk in a multinodular goiter based on the “dominant” nodule has fallen into disfavor.

 Initial evaluation:

The article provides easy to follow algorithm for the initial management of thyroid nodules

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