Should a patient with a goiter and a growing painful thyroid nodule, considering potential underlying conditions such as thyroid cancer or thyroiditis, be evaluated by an endocrinologist?

Endocrinology Referral for Growing Painful Thyroid Nodule in Goiter

Yes, a patient with a goiter and a growing painful thyroid nodule should be evaluated by an endocrinologist, as this presentation requires systematic assessment for malignancy risk, functional status determination, and potential need for fine-needle aspiration biopsy.

Initial Diagnostic Pathway

The evaluation must begin with thyroid function testing, specifically TSH measurement, before any imaging or referral decisions are made 1, 2, 3. The TSH result will guide the entire diagnostic pathway and determine urgency of specialist evaluation 3.

Key Clinical Features Requiring Attention

The combination of growth and pain in a thyroid nodule raises specific concerns:

• Growing nodules warrant heightened suspicion and require ultrasound characterization with ACR TI-RADS criteria to assess malignancy risk 2
• Painful thyroid presentations may indicate subacute thyroiditis, hemorrhage into a nodule, or rapid growth (which can occur with malignancy) 1
• The presence of goiter with a dominant nodule requires evaluation to exclude malignancy, as approximately 5% of thyroid nodules harbor cancer 4, 5

Imaging and Diagnostic Algorithm

Thyroid ultrasound is the mandatory first-line imaging modality after TSH measurement 1, 2, 3. The ultrasound serves multiple critical functions:

• Confirms the mass originates from thyroid tissue 1
• Characterizes nodule features using ACR TI-RADS criteria (composition, echogenicity, margins, calcifications, shape) to stratify malignancy risk 2
• Determines which nodules require fine-needle aspiration biopsy based on size thresholds and suspicious features 2
• Evaluates for cervical lymphadenopathy with superior specificity compared to CT (92% vs 25%) 2

When to Add Cross-Sectional Imaging

CT with contrast should be added if the ultrasound or clinical examination suggests 1, 2:

• Substernal extension of the goiter (CT is superior to ultrasound for this assessment) 1, 2
• Tracheal compression or obstructive symptoms (dyspnea, orthopnea, dysphagia, dysphonia) 1, 2
• Invasive features or bulky lymph node disease 2

Role of Endocrinology Consultation

An endocrinologist should manage this patient because:

• Fine-needle aspiration biopsy decisions require expertise in applying ACR TI-RADS criteria and selecting appropriate nodules for sampling 2, 4
• Interpretation of thyroid function status in the context of nodular disease requires specialist knowledge, particularly if TSH is suppressed (suggesting autonomous function) 3, 4
• Management of indeterminate cytology (follicular neoplasm) requires nuanced decision-making, as most prove benign but surgery is often recommended 4, 5
• Coordination of multidisciplinary care with surgery, radiology, and pathology is best handled by specialists 4

Specific Scenarios Requiring Urgent Referral

Immediate endocrinology consultation is warranted if 4, 5:

• The patient has a history of head and neck radiation exposure
• There is vocal cord paralysis or hoarseness (suggesting recurrent laryngeal nerve involvement)
• Palpable cervical lymphadenopathy is present
• The nodule is firm or fixed on examination
• There is rapid growth over weeks to months

Common Pitfalls to Avoid

Do not proceed directly to radionuclide scanning in a euthyroid patient with a nodular goiter 1, 3. Radionuclide uptake scans have low positive predictive value for malignancy in euthyroid patients, as most nodules are "cold" and most cold nodules are benign 1, 3. Scanning is only indicated when TSH is suppressed to differentiate causes of thyrotoxicosis 3.

Do not skip ultrasound evaluation even if planning specialist referral 2, 3. The ultrasound provides essential information that guides the urgency and type of specialist intervention needed 2.

Do not assume pain indicates benign disease. While subacute thyroiditis is a common cause of thyroid pain, rapid growth of malignant nodules can also cause discomfort 1.

Follow-Up Considerations

If initial evaluation shows benign cytology on fine-needle aspiration and the patient is euthyroid, yearly follow-up with TSH measurement and thyroid palpation is appropriate 6. However, the "growing" nature of this nodule suggests more frequent monitoring may be needed initially, which the endocrinologist will determine based on ultrasound characteristics and growth rate 6, 4.

For patients with large goiters causing compression symptoms, surgical referral becomes necessary regardless of cytology results 6, 4. The endocrinologist will coordinate this decision based on imaging findings and symptom severity 2, 4.