What are the follow-up recommendations for a patient with a subcentimeter thyroid nodule and Hashimoto's thyroiditis who reports a sensation of a lump in the throat?

Management of Subcentimeter Thyroid Nodule in Hashimoto's Thyroiditis with Globus Sensation

For a subcentimeter thyroid nodule in a patient with Hashimoto's thyroiditis reporting a lump sensation in the throat, ultrasound surveillance without fine-needle aspiration is the recommended approach, as TIRADS guidelines do not recommend biopsy for nodules <1 cm regardless of ultrasound features. 1

Understanding the Clinical Context

The sensation of a lump in the throat (globus pharyngeus) is a functional disorder characterized by a recurrent, non-painful but uncomfortable sensation in the absence of true dysphagia or structural pathology. 1

• Globus symptoms are more obvious between meals and improve with eating, often accompanied by throat clearing, sense of mucus buildup, or repeated swallowing 1
• This symptom is commonly linked to psychological stress and high emotional intensity, and may represent a functional disorder rather than direct compression from the small nodule 1
• Globus must be distinguished from true dysphagia—the patient can swallow normally without drooling or excessive oral secretions 1

Diagnostic Approach for the Subcentimeter Nodule

Current TIRADS guidelines explicitly do not recommend FNA biopsy for nodules <1 cm, even when classified as high-risk by ultrasound features. 1

Key Considerations in Hashimoto's Thyroiditis:

• Patients with Hashimoto's thyroiditis have an increased prevalence of thyroid cancer (45.7% vs 29% in those without HT), though most are papillary microcarcinomas with excellent prognosis 2
• The presence of Hashimoto's thyroiditis increases the false-negative rate and indeterminate cytological results during FNA (AUC 91.6% with HT vs 95.9% without HT, p=0.028) 3
• Ultrasound characteristics of malignant nodules are similar in patients with and without Hashimoto's thyroiditis, so standard ultrasound risk stratification applies 2
• The heterogeneous echoic background of Hashimoto's thyroiditis can make nodule evaluation more challenging, but does not change the size threshold for biopsy 4

Recommended Management Algorithm

Initial Assessment:

• Perform comprehensive thyroid ultrasound to document nodule size, echogenicity, margins, calcifications, and vascularity pattern 5, 6
• Evaluate cervical lymph nodes for any suspicious features 5
• Assess thyroid function (TSH, free T4) and confirm Hashimoto's diagnosis with anti-thyroid peroxidase and/or anti-thyroglobulin antibodies if not already documented 7, 8

Surveillance Protocol:

• Implement ultrasound surveillance at 12-month intervals initially for the subcentimeter nodule 5, 6
• Monitor for nodule growth or development of suspicious features that would warrant re-evaluation of biopsy indication 1
• Consider FNA only if the nodule grows to ≥1 cm or develops highly suspicious features such as extrathyroidal extension or pathologic lymphadenopathy 1

Addressing the Globus Sensation

The globus sensation is likely unrelated to the small nodule and represents a functional disorder requiring separate management. 1

Management of Globus Symptoms:

• Reassure the patient that globus is a benign functional condition commonly associated with stress and does not indicate malignancy 1
• Explain that symptoms often improve with stress management and are not caused by the small nodule itself 1
• Consider trial of antidepressants if symptoms are severe, based on evidence in overlapping functional disorders causing esophageal discomfort 1
• Avoid unnecessary interventions such as repeated swallowing or throat clearing, which can perpetuate symptoms 1

Critical Pitfalls to Avoid

• Do not perform FNA on subcentimeter nodules based solely on patient symptoms or ultrasound features, as this contradicts current TIRADS recommendations and may yield indeterminate results, especially in Hashimoto's thyroiditis 1, 3
• Do not attribute globus sensation directly to the small nodule, as this functional symptom is typically unrelated to structural thyroid pathology 1
• Do not delay appropriate surveillance despite the low immediate risk, as Hashimoto's patients have higher cancer prevalence and nodules can grow over time 2, 8
• Be aware that incidental thyroid cancer rates are higher in Hashimoto's patients (33.3% vs 13.0%), emphasizing the importance of consistent follow-up 2

When to Escalate Care

Refer for specialist evaluation if:

• The nodule grows to ≥1 cm on surveillance imaging 1
• New suspicious ultrasound features develop (irregular margins, microcalcifications, extrathyroidal extension) 5, 6
• Suspicious cervical lymphadenopathy appears 5
• True compressive symptoms develop (dysphagia with drooling, dyspnea, dysphonia) rather than functional globus 1, 6
• The patient develops vocal cord paralysis or rapidly growing nodule 9