Should I refer a patient with a palpable goiter and normal thyroid‑stimulating hormone (TSH) and free thyroxine (free T4) levels to an endocrinologist or otolaryngologist?

Should You Refer a Patient with Enlarged Thyroid and Normal TSH/T4?

Yes, refer a patient with a palpable goiter to a specialist even when TSH and free T4 are normal, because the physical finding of thyroid enlargement requires evaluation for malignancy, structural abnormalities, and underlying causes that cannot be excluded by biochemical testing alone.

Why Normal Labs Don't Rule Out Serious Disease

The presence of a palpable neck mass—including goiter—carries risk for malignancy that is independent of thyroid function tests. Thyroid cancer is common in women under age 40, and a palpable thyroid mass requires structural evaluation regardless of TSH levels 1. Normal TSH and T4 simply indicate that the thyroid is producing adequate hormone; they do not assess for:

• Thyroid nodules or masses that may harbor malignancy
• Structural compression of adjacent structures (trachea, esophagus, recurrent laryngeal nerve)
• Multinodular goiter with autonomous function
• Substernal extension requiring surgical intervention

Physical examination is admittedly an imperfect test for identifying malignancy in thyroid masses, with demonstrated limitations even among experienced surgeons 1. This underscores the need for specialist evaluation with imaging and potential biopsy.

Which Specialist to Choose

Endocrinologist for:

• Initial evaluation of goiter etiology
• Assessment for subclinical thyroid dysfunction
• Evaluation of thyroid antibodies (anti-TPO) to identify autoimmune thyroiditis 2
• Coordination of imaging (ultrasound) and fine-needle aspiration if nodules are identified
• Medical management of benign goiter

Otolaryngologist (ENT) for:

• Compressive symptoms (dysphagia, dyspnea, odynophagia) 1
• Voice changes suggesting recurrent laryngeal nerve involvement 1
• Suspected malignancy requiring surgical evaluation 1
• Large goiters requiring surgical debulking

Start with endocrinology referral for most patients with asymptomatic goiter and normal labs. If the patient has compressive symptoms, voice changes, or rapid growth, refer directly to otolaryngology or send to both specialists concurrently 1.

Critical Red Flags Requiring Urgent Referral

Refer immediately (within 2 weeks) if any of these features are present:

• Rapid growth of the thyroid mass 1
• Voice changes (hoarseness, vocal fatigue) suggesting recurrent laryngeal nerve involvement 1
• Compressive symptoms: dysphagia, dyspnea, or stridor 1
• Hard, fixed, or irregular mass on palpation 1
• Cervical lymphadenopathy 1
• History of head/neck radiation (especially in childhood) 1
• Family history of thyroid cancer or MEN syndromes 1
• Age <40 years in women (higher thyroid cancer risk) 1

What the Specialist Will Do

The endocrinologist or otolaryngologist will perform:

1. Thyroid ultrasound to characterize nodules, measure goiter size, assess for suspicious features (microcalcifications, irregular borders, increased vascularity, taller-than-wide shape) 1

2. Fine-needle aspiration (FNA) of any suspicious nodules identified on ultrasound 1

3. Additional thyroid function testing including:

   • Anti-TPO antibodies to identify Hashimoto's thyroiditis 2
   • Thyroglobulin levels if malignancy is suspected 1
   • Repeat TSH and free T4 to confirm euthyroid status 2

4. Assessment for subclinical hyperthyroidism if multinodular goiter is present, as low TSH levels are frequently encountered in patients with multinodular goiter even when free T3 and T4 are normal 3

5. Laryngoscopy if voice changes are present to assess vocal fold mobility before any potential surgery 1

Common Pitfalls to Avoid

Do not assume normal TSH/T4 means the goiter is benign. Thyroid cancer and significant structural disease occur with normal thyroid function 1. Approximately 36% of patients with goiter may have subclinical thyroid dysfunction that becomes apparent with more detailed testing 4.

Do not delay referral waiting for labs to become abnormal. The indication for specialist evaluation is the physical finding of goiter, not biochemical abnormality 1.

Do not miss compressive symptoms. Specifically ask about difficulty swallowing, breathing changes (especially when lying flat), and voice changes 1. These symptoms indicate the need for urgent surgical evaluation.

Do not forget to examine vocal fold mobility preoperatively if surgery is contemplated, as this establishes baseline function and identifies pre-existing recurrent laryngeal nerve injury 1.

Special Considerations

Multinodular Goiter

Low TSH levels occur in 29% of clinically euthyroid patients with multinodular goiter and normal iodine uptake 3. These patients are at risk for developing overt hyperthyroidism and require specialist monitoring even with currently normal free T3 and T4 3.

Suppressive Therapy

If the goiter is diffuse and euthyroid, levothyroxine suppressive therapy can reduce thyroid volume by approximately 20% over 6 months 5. However, this decision should be made by an endocrinologist after excluding malignancy and assessing for contraindications 5.

Post-Radiation Patients

Patients with history of neck radiation require particularly careful evaluation, as 36.4% develop clinical or subclinical hypothyroidism 4. These patients need specialist management regardless of current thyroid function 4.

Bottom Line

Refer all patients with palpable goiter to endocrinology (or otolaryngology if compressive symptoms or voice changes are present) regardless of TSH and T4 values. Normal thyroid function tests do not exclude malignancy, structural complications, or progressive disease. The physical finding of thyroid enlargement is the indication for specialist evaluation, not the laboratory results 1.