Most soft small solitary or single thyroid nodules are asymptomatic and benign. Eighty percent of such small soft thyroid nodule may not need any treatment. Most endocrinologists or physicians favor to observe the nodule by performing periodic examination. Clinical examination includes inspection and palpation of thyroid gland. Palpation test is performed by finger rolled over thyroid gland. Palpation identifies the solitary or single thyroid nodule. Deep palpation helps to recognize soft, firm or hard consistency of thyroid nodule.

The small solitary or single thyroid nodule is often measured between ½ cm to 1 cm in diameter. Soft small painless thyroid nodule if less than 1 centimeter in diameter is often considered benign and not a serious disease. Painful hard solitary or single thyroid nodule should be investigated to rule out cancer. Asymptomatic single thyroid nodule is differentiated as benign or malignant nodule depending on consistency of nodule. The biopsy is performed to confirm the clinical diagnosis following histological studies. Thyroid nodule is surgically removed if nodule becomes firm or hard in consistency or associated with symptoms of hyperthyroidism.

Diagnosis of Small or Large Solitary or Single Thyroid Nodule

Single diffuse larger swelling of thyroid gland of size over 2 to 4 cm is often described as thyroid goiter. The goiter is often associated with increased or decreased secretion of thyroid hormone. Large thyroid swelling resulting in decreased secretion of thyroid hormone is caused by autoimmune disease and known as myxedema.

Large thyroid nodule causes symptoms of hyperthyroidism when nodule secretes thyroid hormone.

Published scientific study suggests 8% of the adult who had thyroid evaluation had single thyroid nodule though most were asymptomatic. Possibility of detection or diagnosis of single thyroid nodule is 10 times higher following ultrasound examination.1 Primary aim following detection or diagnosis of single thyroid hormone is to rule out malignancy. Published research papers suggests 5% of all single thyroid nodules are malignant.1 Solitary thyroid nodule has been also observed in children and young adults though are rare2.

Diagnosis of Small or Large Solitary or Single Thyroid Nodule

Diagnosis of Solitary or Single Thyroid Nodule Based on Symptoms and Signs

In most cases patients suffering with solitary or single thyroid nodule are asymptomatic3. Solitary or single thyroid nodule is occasionally found during routine examination of thyroid gland and neck. Asymptomatic single, soft and painless thyroid nodule is considered benign nodule. Benign single, small or large thyroid lumps, may or may not secrete excessive thyroid hormone. Thyroid nodule or swelling in few cases may cause symptoms of hyperthyroidism when nodule secretes excessive amount of thyroid hormone. Similarly single large thyroid nodule may not secrete any thyroid hormone and may cause relatively low thyroid hormone resulting in hypothyroidism. Such condition is known as hypothyroidism or goiter.

Symptomatic Classification of Solitary or Single Small and Large Thyroid Nodule is as follows-

  1. Small Thyroid Nodule: Soft and Single

    1. Normal Secretion of Thyroid Hormone-

      • Patient is asymptomatic.
      • Single soft painless thyroid nodule of 0.5 to 1 cm in diameter is felt during clinical examination.
      • Blood test indicates normal level of thyroid hormone.
      • Radiological study indicates absence of cyst, calcification and fibrotic tissue.
      • Diagnosis is possible benign thyroid nodule.
    2. Increased Secretion of Thyroid Hormone-

      • Quantity of thyroid hormone secreted by single small nodule often does not cause hyperthyroidism.
      • Most patients are asymptomatic.
      • Single soft painless thyroid nodule of 0.5 to 1 cm in diameter is felt during clinical examination.
      • Thyroid blood hormone level is normal or marginally increased.
      • Radiological study indicates absence of cyst, calcification and fibrotic tissue.
      • Diagnosis is possible benign thyroid nodule.
    3. Small Thyroid Nodule: Firm to Hard

      • Solitary or single small thyroid nodule (1.5 to 2 cm in diameter).
      • Asymptomatic, blood level of thyroid hormone is normal and swelling does not cause compression of trachea or esophagus.
      • Single firm to hard tender thyroid nodule felt during palpation.
      • Radiological study indicates presence of cyst, calcification and fibrotic tissue within the nodule.
      • Blood test indicates normal level of thyroid hormone.
  2. Large Thyroid Nodule: Soft and Single

    1. Normal Secretion of Thyroid Hormone-

      • Large single thyroid nodule (2 to 4 cm in diameter or larger). Size is confirmed with ultrasound examination.
      • Examination indicates soft consistency of single large thyroid nodule.
      • Symptoms caused by compression of trachea or esophagus may be observed.
      • Most patients are asymptomatic when secretion of thyroid hormone is marginal.
      • Thyroid blood hormone level may be marginally increased or normal.
      • Radiological study may not show presence of cyst, calcification and fibrotic tissue within the nodule.
      • Needle biopsy suggests benign tumor.
    2. Decreased Level of Thyroid Hormone

      • Large solitary or single thyroid nodule (over 2 cm in diameter).
      • Symptoms of hypothyroidism are observed. The condition is known as hypothyroidism or myxedema.
      • Symptoms caused by compression of trachea or esophagus may be observed.
      • Single painless large thyroid nodule felt during palpation.
      • Blood examination indicates significant decrease of thyroid hormone.
      • Radiological study indicates calcification and fibrotic tissue spread within the swollen thyroid gland.
    3. Increased Level of Thyroid Hormone-

      • Large solitary or single thyroid nodule (over 2 cm in diameter).
      • Symptoms of hyperthyroidism are observed.
      • Symptoms caused by compression of trachea or esophagus may be observed.
      • Single painless large thyroid nodule felt during palpation.
      • Blood examination indicates significant increase of thyroid hormone.
      • Radiological study indicates absence of cyst, calcification and fibrotic tissue.
      • Needle biopsy does not indicate malignancy.
  3. Large Thyroid Nodule: Firm to Hard

    • Solitary or single large thyroid nodule (over 2 cm in diameter).
    • Predominant symptoms are hoarseness of voice or difficulties in swallowing.
    • In few cases enlarged thyroid gland is active and secretes thyroid hormone resulting in symptoms of hyperthyroidism.
    • Single firm to hard tender large thyroid nodule is felt during palpation.
    • The blood level of thyroid hormone is normal or increased.
    • Large firm to hard swelling often causes compression of trachea or esophagus.
    • Radiological study indicates presence of cyst, calcification and fibrotic tissue within the nodule.
    • Ultrasound study suggests encroachment of thyroid gland over adjacent trachea and esophagus.

Symptoms of Hyperthyroidism-

  • Intolerance to heat
  • Irregular heart beats
  • Nervousness
  • Tremors are observed in extremities.

Symptoms of Hypothyroidism-

  • Increased sensitivity to cold
  • Dry skin
  • Weight gain
  • Puffy face
  • Muscle weakness
  • Fatigue
  • Thinning hair
  • Constipation
  • Slowed heart rate
  • Muscle aches, tenderness and stiffness
  • Pain, stiffness or swelling in your joints
  • Depression
  • Loss of memory.

Symptoms Caused by Compression of Trachea and Esophagus-

Symptoms of Laryngeal and Tracheal Irritation-

  • Hoarseness
  • Shortness of breath
  • Highly suspicious possible malignant nodule
  • Difficulty swallowing
  • Pain is felt behind thyroid gland and larynx (voice box) during swallowing and examination.

Blood Examination for Diagnosis of Solitary or Single Thyroid Nodule

  • TSH level- Increased blood level of thyroid stimulating hormone (TSH) is observed in patient suffering with hypothyroidism.
  • 0.4: Normal
  • 2.5: At risk
  • 4.0: Mild hypothyroidism
  • 10.0: Hypothyroidism.
  • Total or Free Thyroxin (T4)- Level is increased in patients suffering with hyperthyroidism; similarly decreased level is observed in patient suffering with hypothyroidism.
  • Total Triiodothyronine (T3)- Level is increased in patients suffering with hyperthyroidism; similarly decrease level is observed inpatient suffering with hypothyroidism.
  • Cholesterol- Decreased cholesterol level is observed in-patient suffering with hypothyroidism.

Ultrasound Study to Diagnose Solitary or Single Thyroid Nodule

  • Ultrasound study of thyroid gland and nodule is performed to evaluate the size of thyroid nodule and also examine the abnormal histological tissue changes of nodule compared to normal gland.
  • Ultrasound study helps to differentiate normal thyroid tissue from abnormal thyroid tissue.
  • Ultrasound study helps in diagnosing fibrotic changes, cystic changes and abnormal calcium deposits within the deposits. Additional abnormal tissue changes observed are increased vascularity, micro-calcifications, irregular margins, and the absence of a halo. These changes are often observed in patients suffering with malignant disease of single thyroid nodule.
  • Study published by Rosario et al suggests the rate of malignancy diagnosed following biopsy and cytological study is about 2% of all cases diagnosed as highly suspicious possible malignant nodule following ultrasound examination.3

Radio Isotope Study for Diagnosis of Solitary or Single Thyroid Nodule -

  • Radioactive iodine (RAI) scanning is performed to evaluate the functional status of thyroid nodules. Cold or inactive nodules were considered more likely malignant. The results are often considered false positive in Euthyroid (normal hormone secreting) patients.4
  • The scientific radio isotope thyroid nodule studies published suggest 80 to 85% of thyroid nodules are cold, and about 10% of these nodules represent a malignancy.

Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)

  • Imaging studies such as CT scan or MRI does not help to differentiate small hard cancerous thyroid nodule from benign soft nodule.
  • The radiological studies such as MRI and CT scan are performed with contrast to evaluate the spread of larger thyroid swelling over adjacent tissue in patients suffering with symptoms suggesting compression of larynx or esophagus.

Fine Needle Aspiration Biopsy for Diagnosis of Solitary or Single Thyroid Nodule -

  • The Fine Needle Biopsy involves needle placement within the solitary or single thyroid nodule under CT Scan or MRI or Ultrasound guidance.
  • The tissue removed from solitary or single thyroid nodule is examined to differentiate benign and malignant nodule.5 Histological studies of biopsy samples are performed to identify signs of malignancy.
  • Endocrinologist, oncologist (cancer specialist) and surgeon will carefully evaluate the findings of histological study prior to surgical removal of small or large nodule.
  • In many cases FNAB is repeated after 3 months when prior study was negative for cancer.

Frozen Section Analysis-

  • Frozen section analysis is performed during surgery.
  • Surgeon will send biopsy samples of nodule once the nodule is surgically exposed. The biopsy sample is frozen and the thin section of frozen sample is examined under microscope.
  • The results are available in 15 to 30 minutes.
  • Presence of malignant activities indicates necessity of removing entire thyroid gland and lymph node. If biopsy results suggest absence of malignant cells then surgeon will remove only nodule.6

Also Read:

References

  1. Management of the solitary thyroid nodule.
    Oncologist. 2008 Feb;13(2):105-12. doi: 10.1634/theoncologist.2007-0212.
    Yeung MJ1, Serpell JW.

  2. Solitary thyroid nodules in children and adolescents
    Journal of Pediatric Surgery: Volume 17, Issue 3, June 1982, Pages 225-229
    Wellington Hung 1, *, Gilbert P. August 1, Judson G. Randolph 1, Richard M. Schisgall 1, Roma Chandra 1

  3. Thyroid nodules with highly suspicious ultrasonographic features, but with benign cytology on two occasions: is malignancy still possible?
    Rosário PW1, Calsolari MR1.
    Arch Endocrinol Metab. 2016 Aug;60(4):402-4.

  4. Radioactive iodine scanning is not beneficial but its use persists for euthyroid patients.
    Panneerselvan R1, Schneider DF, Sippel RS, Chen H.
    J Surg Res. 2013 Sep;184(1):269-73.

  5. Cytopathologic diagnosis of fine needle aspiration biopsies of thyroid nodules.
    Misiakos EP1, Margari N1, Meristoudis C1, Machairas N1, Schizas D1, Petropoulos K1, Spathis A1, Karakitsos P1, Machairas A1.
    World J Clin Cases. 2016 Feb 16;4(2):38-48.

  6. Optimal timing for a repeat fine-needle aspiration biopsy of thyroid nodule following an initial nondiagnostic fine-needle aspiration.
    Deniwar A1, Hammad AY1, Ali DB1, Alsaleh N1, Lahlouh M1, Sholl AB2, Moroz K2, Aslam R3, Thethi T4, Kandil E5.
    Am J Surg. 2016 Jun 14.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: September 7, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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