From the Guidelines
The best next step for evaluating this patient is to perform a thyroid ultrasound. This 72-year-old woman presents with a 2-3 cm neck swelling in the anterior triangle that moves with swallowing, which is highly suggestive of a thyroid nodule. Her elevated TSH level of 8.03 μU/mL indicates subclinical hypothyroidism, as noted in the study by 1. Thyroid ultrasound is the preferred initial imaging modality for thyroid nodules as it can characterize the nodule's size, composition (solid, cystic, or mixed), and features that might suggest malignancy. It can also assess for additional nodules and evaluate cervical lymph nodes. The ultrasound findings will guide further management, which may include fine-needle aspiration biopsy if suspicious features are present. This approach is particularly important given the patient's age, as thyroid nodules in older individuals carry a higher risk of malignancy, even though she lacks other concerning features such as voice changes, rapid growth, or family history of thyroid cancer. The normal calcium and phosphorus levels suggest that hyperparathyroidism is unlikely to be the cause of her neck swelling. According to the study by 1, the serum TSH test is the primary screening test for thyroid dysfunction, and follow-up testing of serum T4 levels in persons with persistently abnormal TSH levels can differentiate between subclinical and overt thyroid dysfunction.
Some key points to consider in this patient's evaluation include:
- The patient's elevated TSH level and the presence of a thyroid nodule, which warrant further investigation with thyroid ultrasound.
- The importance of characterizing the nodule's features to assess the risk of malignancy, as noted in the study by 1.
- The need to consider the patient's age and the potential for malignancy, even in the absence of other concerning features.
- The role of thyroid ultrasound in guiding further management, including the potential for fine-needle aspiration biopsy.
Given the patient's presentation and laboratory findings, thyroid ultrasound is the most appropriate next step in her evaluation, as it will provide valuable information to guide further management and potential treatment.
From the Research
Evaluation of Thyroid Nodules
The patient presents with a swelling in the anterior triangle of her neck, which moves superiorly when she swallows, suggesting a thyroid nodule. The best next step for evaluating this patient would be to perform an ultrasound examination of the thyroid gland, as it is a rapid and radiation-free method that can provide important information about the nodule 2, 3.
Laboratory Findings
The patient's laboratory findings show an elevated thyroid stimulating hormone (TSH) level, which may indicate hypothyroidism. However, the patient does not exhibit any symptoms of thyroid dysfunction. The TSH level is not very useful for assessing adequate thyroxine dosage in patients with primary hypothyroidism 4.
Next Steps
Based on the patient's presentation and laboratory findings, the next steps would be:
- Perform an ultrasound examination of the thyroid gland to evaluate the nodule 2, 3
- Consider fine-needle aspiration biopsy if the nodule is large enough or has suspicious sonographic features 2, 5
- Monitor the patient's TSH levels and consider treatment if the levels remain elevated 5
Key Considerations
- Thyroid ultrasound is indicated for assessment of palpable goitre and thyroid nodules, but not for routine assessment of hyperthyroidism or hypothyroidism 5
- Overzealous use of ultrasound can lead to overdiagnosis of thyroid cancer 5
- The health impact of subclinical hypothyroidism with mildly elevated levels of TSH remains uncertain, particularly in older people 5