Approach to Thyroid Masses

History
1. Pain
Causes of Pain in Thyroid
 Rupture into cyst
 Thyroiditis
 Abscess
 Malignancy
2. PMHx/PSHx
3. Hyper/Hypothyroid sx + Mass sx
4. Fam Hx of Thyroid cancers/MEN/Grave’s

Physical Examination
1. Thyroid mass exam
2. Nodes
3. Vocal cords

Mechanism of swallowing and sticking out tongue

- Thyroglossal cyst usu. in front of hyoid
- Thyroid gland descends behind to reach cricoid cartilage on trachea

Diagnosis
 Both sides of thyroid involved – Graves vs MNG
 One-sided thyroid mass
o Benign – adenoma, cyst (Cyst is 2nd, adenoma is 3rd commonest)
o Malignant – carcinoma
o Rmb! The commonest cause this is actually MNG!
 Thyroid cyst grows out of the thyroid so it feels like a ping pong ball esp if recent
haemorrhage vs adenoma which is harder to feel the edges of (similar to MNG)
 ECA branch from level of hyoid bone;
 Venous drainage, with lymphatic following
 Hence, you expect it go to level 6 (commonest), and also 2,3,4, (5 is possible, 1
almost never) **
 RLN paralysed away from midline (can breathe but cannot talk) vs closer to midline
 It is possible for a person to have a normal voice and yet have cord paralysis

Investigations
 Bloods – if there is 1 test to do, TSH*
 Thyroid u/s
o Unilateral or bilateral TRO MNG
o Cystic or solid
o Haemorrhage (density is thicker?)
o Features of malignancy
o Calcifications: coarse or micro ; Papillary thyroid carcinoma (recognise!)
 Thyroid nuclear scan
 CT/MRI

If there is a nodule, low TSH, and thyroid scan is hot i.e. functioning nodule, no need to
investigate further.
Indications for CT/MRI
 Suspicion of malignancy (compressive, fixity, LN)
MRI
 Magnets send a field throughout you, excite electrons in water and fat (H+ ions)

FNAC
 Fine needle tells you cytology (not histo)
 If diagnosis is colloid nodular goitre, wait and monitor TRO MNG
 Psamomma bodies are keratin pearls that undergo dystrophic changes
 If papillary ca, hemthyroidectomy w frozen section KIV total (purpose of doing frozen
section)
 Hematoma post surgery

Stage a thyroid cancer down the road

 RAI will be picked up by any remaining thyroid cells (from metastases since this
patient is post-thyroidectomy)
 Give exogenous thyroid ; dose should be high to suppress TSH (to like 0.1 to prevent
recurrence) Note: Not physiological dose of thyroixine

To monitor recurrence
 Thyroglobulin should be zero
 Can get pregnant 1 year after cessation of RAI *