Intended for healthcare professionals

Clinical Review

Investigating the thyroid nodule

BMJ 2009; 338 doi: (Published 13 March 2009) Cite this as: BMJ 2009;338:b733
  1. H M Mehanna, director1,
  2. A Jain, clinical research fellow1,
  3. R P Morton, professor, ENT2,
  4. J Watkinson, consultant, ENT3,
  5. A Shaha, professor4
  1. 1Institute of Head and Neck Studies and Education, University Hospital, Coventry CV2 2DX
  2. 2Head and Neck surgery, Counties Manukau District Health Board ENT, Manukau Super Clinic, Manukau, Papakura, Franklin, New Zealand
  3. 3Head and Neck surgery, Department of Otorhinolaryngology Head and Neck Surgery, University Hospital, Birmingham, United Kingdom
  4. 4Division of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York
  1. Correspondence to: H M Mehanna, Consultant Head and Neck Surgeon, and Honorary Associate Clinical Professor, Director, Institute of Head and Neck Studies and Education, University Hospitals Coventry, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom Hisham.Mehanna{at}
  • Accepted 16 January 2009

Summary points

  • Thyroid nodules are common, but only about 5% are malignant

  • The risk of malignancy is similar for solitary nodules and multinodular goitres

  • Urgent referral to secondary care is necessary only if the nodule is growing rapidly (over few weeks) or associated with stridor, hoarseness, or cervical lymphadenopathy

  • Needle aspiration biopsy is the most accurate method of investigation. Its accuracy is improved by ultrasound guidance. Ultrasonography can also add useful information and can improve accuracy.

  • Management depends mainly on the results of needle aspiration but should also take into consideration the clinical and ultrasound features

Thyroid nodules are common: 4-7% of the adults have a palpable nodule, and up to 50-70% will have nodules on high definition ultrasonography, which may cause considerable concern to patients. In this article, we present an evidence based guide to investigating and managing thyroid nodules and we discuss the myths about nodules. Where relevant, we also highlight the differences between the two most widely used guidelines on this topic: the recently issued second edition of the British Thyroid Association’s guidelines on thyroid cancer1 and the American Thyroid Association’s guidelines.2 These guidelines were formulated by two large committees of experts, who reviewed all the available evidence, which mainly consists of prospective and retrospective cohorts; where there was no evidence, expert consensus opinion was used.

What is the risk of a thyroid nodule being malignant?

Traditional teaching states that 20-40% of thyroid nodules are malignant.3 However, this pertains to a highly selected group of patients, with solitary cold nodules on scintigraphy.4 The risk of malignancy for a thyroid nodule identified on ultrasonography is much lower: 4-7%.5 6

When to refer a patient with a thyroid nodule to secondary care

Little evidence is available on referral times. Relying on expert opinion, the British Thyroid Association’s guidelines say that most thyroid nodules are benign and therefore do not require urgent referral to secondary care.1 This advice …

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