In a patient with a 7 × 5 × 6 mm solid hypoechoic thyroid nodule with irregular margins, a history of melanoma, and prior radioactive iodine treatment for Graves disease, does the presence of globus sensation alter the recommended work‑up?

Does Globus Sensation Alter Work-Up for a 7 mm Hypoechoic Thyroid Nodule?

No—globus sensation does not change the diagnostic approach for this subcentimeter nodule, because current TIRADS guidelines explicitly recommend surveillance without FNA for nodules <1 cm regardless of ultrasound features, and globus is typically a functional disorder unrelated to small thyroid nodules. 1

Understanding the Clinical Context

The presence of globus sensation in this scenario is almost certainly unrelated to the 7 mm nodule itself. Research demonstrates that thyroid nodules causing true globus symptoms are typically >3 cm in size and located anterior to the trachea—characteristics that do not apply to this patient's small nodule. 2

• Globus symptoms are more obvious between meals, improve with eating, and are often accompanied by throat clearing or a sense of mucus buildup—features that suggest a functional rather than structural etiology. 1
• This symptom is commonly linked to psychological stress, laryngopharyngeal reflux, or high emotional intensity, not direct compression from small thyroid lesions. 1
• True dysphagia (difficulty swallowing with drooling or excessive oral secretions) would be absent in functional globus. 1

Standard Management for Subcentimeter Nodules

The size threshold of 1 cm is the critical determinant for FNA decision-making, not the presence of symptoms or suspicious ultrasound features. 3, 1

Current TIRADS Recommendations

• TIRADS guidelines explicitly do not recommend FNA biopsy for nodules <1 cm, even when classified as high-risk (TR4 or TR5) by ultrasound features. 4, 3, 1
• This approach aims to avoid overdiagnosis of papillary microcarcinomas that have minimal impact on mortality or quality of life. 3, 1
• The 7 mm nodule falls below this threshold and should be managed with surveillance regardless of its hypoechoic appearance and irregular margins. 1

Surveillance Protocol

• Implement ultrasound surveillance at 12-month intervals initially to monitor for growth or development of new suspicious features. 1
• Document nodule size, echogenicity, margins, calcifications, and vascularity pattern at each visit. 1
• Evaluate cervical lymph nodes for any suspicious features (loss of fatty hilum, microcalcifications, cystic change). 1

Special Considerations in This Patient

History of Melanoma

While the patient has a history of melanoma, this does not independently alter the FNA threshold for subcentimeter thyroid nodules. The standard size-based criteria still apply. 3

Prior Radioactive Iodine for Graves Disease

• Previous RAI treatment for Graves disease does not independently increase thyroid cancer risk but also does not eliminate the possibility of cancer in residual thyroid tissue. 1
• RAI can cause significant cytologic atypia, which would further complicate interpretation if FNA were performed on this small nodule. 5
• In Graves disease patients, cytomorphologic changes may mimic nuclear features of papillary thyroid carcinoma, making FNA of small nodules particularly prone to indeterminate results. 5

Hashimoto Thyroiditis Context

If this patient has underlying Hashimoto thyroiditis (common in post-Graves patients), performing FNA on a subcentimeter nodule is even less advisable:

• Benign hyperplastic/adenomatoid nodules in Hashimoto thyroiditis are typically solid and isoechoic. 3
• TIRADS guidelines specifically do not recommend biopsy for nodules <1 cm in Hashimoto patients regardless of ultrasound features. 1

When to Escalate Care

FNA should be considered only if specific high-risk features develop during surveillance: 3, 1

• Nodule grows to ≥1 cm in any dimension
• Development of extrathyroidal extension on ultrasound
• Appearance of pathologic cervical lymphadenopathy (loss of fatty hilum, microcalcifications, cystic change)
• True compressive symptoms develop (dysphagia with drooling, dyspnea, dysphonia)—not functional globus

Critical Pitfalls to Avoid

• Do not perform FNA based solely on patient symptoms or suspicious ultrasound features when the nodule is <1 cm, as this contradicts current TIRADS recommendations and may yield indeterminate results. 3, 1
• Do not attribute globus sensation directly to the small nodule, as this functional symptom is typically unrelated to structural thyroid pathology and requires separate management (stress reduction, treatment of reflux). 1, 2
• Do not override size-based guidelines even in patients with prior malignancy history, as the evidence shows that subcentimeter nodules managed with active surveillance have low progression rates. 3

Addressing the Globus Symptom

• 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 evaluation for laryngopharyngeal reflux or other common causes of globus if symptoms persist. 1