Management of Tender Thyroid Nodules
A tender thyroid nodule requires comprehensive ultrasound evaluation with fine-needle aspiration biopsy (FNAB) for nodules meeting size and risk criteria to rule out malignancy, followed by appropriate treatment based on cytology results. 1
Initial Assessment
Clinical Evaluation
- Assess for associated symptoms:
- Pain characteristics (constant vs. intermittent)
- Rapid growth
- Compressive symptoms (dysphagia, dysphonia, dyspnea)
- Fever or signs of infection
- Risk factors for malignancy:
- History of head and neck irradiation
- Family history of thyroid cancer
- Age <15 years or male gender
- Associated syndromes with thyroid cancer risk
Laboratory Testing
- Thyroid function tests (TSH, free T4)
- Consider inflammatory markers if infection suspected
Imaging
Ultrasound Assessment
- Request comprehensive thyroid ultrasound with specific evaluation of:
- Nodule characteristics (size, echogenicity, composition)
- Vascularity pattern
- Margins (regular vs. irregular)
- Presence of microcalcifications
- TI-RADS risk stratification
- Relationship to adjacent structures
- Cervical lymph node assessment 1
Suspicious Ultrasound Features
- Solid composition
- Hypoechogenicity
- Irregular margins
- Microcalcifications
- Spherical shape (higher risk of malignancy than ovoid nodules) 2
- Intranodular vascularization
Diagnostic Procedures
Fine-Needle Aspiration Biopsy
- Indicated for:
- Solid nodules >1cm with suspicious features
- Any size nodule with highly suspicious features in high-risk patients 1
- Tender nodules with concerning ultrasound features
Management Based on Cytology Results
Benign Nodules
- For tender benign nodules:
Malignant or Suspicious Nodules
- Surgical management:
- Total or near-total thyroidectomy for tumors ≥1cm
- Consider less extensive procedures for small, intrathyroidal tumors with favorable histology 3
Treatment Options for Symptomatic Benign Nodules
Conservative Management
- NSAIDs for pain relief
- Patient education about benign nature and self-monitoring 1
Interventional Options
- Thermal ablation recommended for:
- Benign dominant thyroid nodules causing clinical symptoms
- Nodules ≥2cm with gradual increase in size 3
Surgical Options
- Consider if:
- Persistent tenderness despite conservative measures
- Progressive growth
- Compressive symptoms
- Cosmetic concerns
Follow-up Protocol
- Initial follow-up one month after any procedure
- Subsequent assessments at 3,6, and 12 months during the first year
- Annual follow-up for benign nodules thereafter 3
- Monitor for:
- Changes in nodule size (volume reduction rate)
- Improvement of symptoms
- Development of new symptoms
- Recovery from complications
Special Considerations
Nodule Rupture
- Rare complication (0.08%-0.21%)
- Presents with acute neck pain, swelling
- Management:
- Early administration of NSAIDs improves prognosis
- Analgesia and possible drainage for symptomatic cases
- Surgical excision may be necessary for extensive cellulitis 3
Pregnancy
- Propylthiouracil preferred in first trimester for hyperthyroid nodules
- Switch to methimazole after first trimester
- Use lowest effective dose to maintain FT4 in upper normal range 1
Pitfalls to Avoid
- Don't assume all tender nodules are benign inflammatory conditions
- Don't overlook the need for FNAB in nodules meeting size and risk criteria
- Don't miss evaluation of cervical lymph nodes during ultrasound assessment
- Avoid overtreatment of micropapillary carcinomas (<1cm), which have excellent prognosis 1
Remember that while most thyroid nodules are benign (95%), thorough evaluation is essential to identify the small percentage that may harbor malignancy 4, 5.