Thyroid Nodules

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Thyroid nodules are abnormal growths or swellings occurring in the thyroid gland. Most nodules are not cancerous (they are benign) and do not create problems. Many of them do not even require treatment.
Only about 5% of the nodules are cancerous. They must be excised surgically. Very rarely, the nodules cause thyroid problems. When a nodule produces too many thyroid hormones, hyperthyroidism occurs, the gland is overactive or hyperfunctional.



It is not know the exact cause of thyroid nodules. However, it is known that those exposed to radiation have a higher risk of developing thyroid nodules. Exposure to environmental radiation or the previous therapeutic radiation to the head, neck or chest (especially during childhood) increases the risk of thyroid nodules.
Experts estimate that thyroid nodules are transmitted genetically. So if a parent had thyroid nodules, children have a higher risk of having nodules. If another problem is associated to the gland (goiter for example) the risk of thyroid nodules is higher.


Most nodules are asymptomatic and are unnoticed. They are often discovered at a routine examination or at investigations such as computed tomography or ultrasound performed for other reasons. If your thyroid nodule is big, then it is palpable or it may be noticed an increase in the volume of the neck.
In rare cases the following may be experienced:
- Pain or a sensation of fullness in the neck;
- Difficulty in swallowing;
- Difficulty in breathing;
- Nervousness, tachycardia, sweating, weight loss or other symptoms of hyperthyroidism (an excess of thyroid hormones);
- Fatigue or depression, memory problems, constipation, dry skin, feeling cold or other symptoms of hyperthyroidism or hypothyroidism (deficiency of thyroid hormones)
Other conditions that cause similar symptoms are hyperthyroidism and thyroiditis.

Physiopathogenic mechanism

Most thyroid nodules are benign and do not cause any problems. They are often difficult to observe because they are very small. Many people have nodules that are never discovered or treated. There are three types of thyroid nodules: solid nodules, nodules filled with fluid (cystic) and partially cystic nodules. There can be solitary or multiple nodules (multinodular goiter).
Also, solid and cystic nodules can coexist. Solid nodules grow slowly. Very rarely cystic nodules bleed, which may lead to a sudden increase in volume and causes pain. Thyroid nodules do not usually interfere with the function of the gland.
However, sometimes a benign nodule can cause:
- Hyperthyroidism, when one or more nodules produce thyroid hormone in excess, hyperthyroidism is treated with antithyroid medication, possibly radioactive iodine and very rarely with surgery; the hyperthyroidism caused by nodules is unusual and occurs in fewer than 1% of people with thyroid nodules ;
- Difficulty in breathing or swallowing, when one or more nodules press the trachea or the esophagus; these nodules need surgical excision. Only about 5% of the nodules are malignant. Thyroid cancer is usually discovered and treated early, so most people evolve favorably.

Risk Factors

Possible risk factors:
- Age – thyroid nodules are more common in elderly people;
- Females;
- Exposure to radiation: radiation from the environment or previous radiotherapy to the neck, head or chest (especially during childhood) increases the risk of thyroid nodules;
- Iodine deficiency, which can lead to the appearance of goiter with or without nodules; in our country iodine is added to salt, some food or water;
- Presence of Hashimoto thyroiditis, which causes an underactive thyroid (hypothyroidism);
- One or both parents had thyroid nodules.
Most nodules are benign.
A nodule is more likely to be malignant if:
- The patient was exposed to radiation; although rare, thyroid cancer can occur even after 20 years after the radiation therapy or exposure to radiation in the environment;
- Family members have cancer of the endocrine glands, including thyroid;
- It occurs in people under 20 or over 60 years;
- Males;
- Nodule growing rapidly in weeks or months; however, just because a nodule grew in volume this does not necessarily mean that is malignant;
- A nodule appears during pregnancy;
- Graves Basedow disease is present;
- Hashimoto thyroiditis had previously existed.

Consulting a specialist

It is recommended to consult a specialist if there are signs and symptoms of thyroid nodules:
- Any swelling in the neck that does not disappear in two weeks;
- Hoarseness not caused by cold or throat infection and persistence of more than one month;
- Difficulty in swallowing;
- Symptoms of a thyroid dysfunction (fatigue, weakness, or sudden weight loss).
In the case of a surgical extirpation of a portion of the thyroid gland due to a benign node, regular medical checkups for the evidence of any changes occurring in the gland are required.

Watchful waiting

During this period the patient and the doctor notice the symptoms and signs without using drugs. Watchful wait is not recommended if you have thyroid nodules. If there appears any swelling in the neck, which does not disappear, or snoring, difficulty in swallowing or symptoms of thyroid dysfunction, it is recommended to consult a specialist.
Recommended medical specialists:
- Family doctors or general practitioners;
- Doctors of internal medicine
- Pediatricians;
- Trained medical aid.
Your doctor might head you to an endocrinologist for further investigation and treatment. If you need special investigation it is indicated to consult:
- A nuclear medicine physician, specialized in using various radioactive substances;
- The surgeon;
- The ENT (ear, nose and throat specialist).


The first step in diagnosing thyroid nodules is the physical examination and medical history research. Thyroid nodules are often detected during physical examination, CT scan or ultrasound to the neck, thorax or head, done for other diseases. Most people do not detect nodules by themselves because they are difficult to feel and do not cause symptoms. If your doctor finds a nodule, he will lead you to an endocrinologist for investigation and treatment.
The common investigations for thyroid nodules are:
- Testing the thyroid-stimulating hormone- a blood exam to determine the thyroid function;
- Thyroid biopsy to see if the nodule is malignant. This involves taking a portion of the thyroid nodule, which can be done to the medical center.
Other additional tests:
- Thyroid hormone testing to determine if the nodule produces excess or deficiency of hormones;
- Determination of calcitonin to detect cancer. This test is performed if there is a family history case of thyroid cancer or other type of cancer of the endocrine glands;
- Thyroid scan, using radioactive materials and a camera to record images in order to determine the gland function and the possible hyperthyroidism;
- Thyroid ultrasound which shows a reflected image of the gland;
The ultrasound can not determine whether a nodule is cancerous or not, but it helps to:
- Confirm the presence of nodules which other tests have failed to;
- To see the evolution of the nodules if they do not disappear;
- Find the thyroid for biopsy.
Subsequent examinations
If the nodule is not cancerous, it will be examined once a year. The testing of the thyroid-stimulating hormone might be performed in order to asses the gland function. The ultrasound will show whether the size of the nodule has changed or not. If a growth took place, another biopsy and surgery will be required. If the thyroid was removed due to cancer, your doctor will investigate thyroglobulin, a protein produced by both normal and tumor cells. High levels of thyroglobulin may mean the dissemination of cancer to other organs.
Biopsy is the only method of verifying if a nodule is malignant or not.
Cancer is more likely if ithe following are present:
- One hard nodule, of a very different consistency from the rest of the thyroid or other thyroid nodules;
- Lump growing in weeks or a few months;
- Nodule which is not mobilized to touch;
- Swollen ganglions in the neck;
- Hoarseness or changed voice that does not disappear.

Treatment – Overview

The treatment depends on the effect produced by these nodules. If the nodule is benign and causes no problems, it will be closely monitored without using anything else. If symptoms appear, medication or surgery may be required. Antithyroid drugs and radioactive iodine can treat nodules that cause hyperthyroidism.
Surgery is necessary only if the nodule is so large that it interferes with breathing or swallowing or if it is malignant. After the surgical removal of a malignant nodule, radioactive iodine may be necessary in order to destroy any remaining tissue or cancer cells that create problems. If total thyroidectomy is needed, thyroid hormones will be administred for the entire life.

Initial treatment

Once diagnosed the nodule, the following options are possible:
1. Observation of a nodule which is not cancerous, which can be seen every 6 or 12 months for any change in shape; many nodules do not change in size, but even diminish without treatment;
2. Thyroid Biopsy: Your doctor may remove fluid with a needle from a cystic nodule; sometimes, after such a drainage, cystic nodules may disappear, but most of them recover;
3. Thyroidectomy, which is not always necessary; surgery is required if:
- the nodule seems or it is cancerous;
- it interferes with breathing or swallowing because of its size ;
- the cystic nodule recovers after drainage;
4. Thyroid-stimulating hormone suppression therapy is used to shrink a nodule if:
- the nodule is benign;
- the nodule seems or it is cancerous, but the patient can not withstand surgery;
5. Radioactive iodine can be used to destroy the thyroid tissue if:
- the nodule is benign but it produces too much thyroid hormone, causing hyperthyroidism; if this situation occurs during pregnancy, the treatment with radioactive iodine is not indicated, instead surgery is recommended;
- the multinodular goiter is present and surgery can not be performed because of other diseases; radioactive iodine diminishes the nodules that interfere with breathing or swallowing, though they can recover after completing the therapy.

Maintenance treatment

If the thyroid nodules exist, it is necessary to:
- Follow the hormone therapy prescribed by the specialist, at the same hour every day and without omitting any administration;
- Consult your doctor if symptoms of hyperthyroidism, like nervousness, tachycardia, more sweating and weight loss appear; sometimes hyperthyroidism occurs while taking thyroid hormones or when a node produces too much thyroid hormones;
- Consult your doctor if symptoms of hypothyroidism, such as fatigue, unmotivated cold feeling and weight gain appear; hypothyroidism may occur after treatment with radioactive iodine or after surgery;
- Schedule regular checkups to the specialist; even benign nodules should be examined by the doctor.
Treatment if the disease gets worse
Regardless of the therapeutic scheme that was chosen:
- hormonal treatment is administered at the same time every day;
- any symptoms of hyperthyroidism, as nervousness, tachycardia and palpitations, sweating and weight loss must be monitored; a benign nodule can produce an excess of thyroid hormones causing hyperthyroidism, as hormonal medication also does;
- hypothyroidism symptoms as fatigue, sensitivity to cold and weight gain must be monitored. The appearance of these symptoms, which may be caused by the radioactive iodine or surgery, will be announced to the specialist.
If changes of the nodule do not appear, this can be kept under observation. If its size changes or other changes occur, it may be suggested to do another biopsy, a thyroid-stimulating hormone hormone testing or to make a nodule excision surgery (thyroidectomy). If a partial or total removal of the thyroid gland is necessary, radioactive iodine will be used in order to destroy any remaining tissue. The specialist may also recommend the thyroid-stimulating hormone suppression therapy to prevent the recurrence of thyroid nodules or other cancer cell growth.


If the nodule grows, it is recommended another aspiration biopsy. If the nodule seems or it really is cancerous, surgery is recommended in order to remove a part or the entire thyroid. If thyroid nodules appear after the therapeutic radiation of the head, neck or chest and the thyroid was previously partially excised, after the surgery the thyroid-stimulating hormone suppression therapy will be performed in order to prevent the recurrence of nodules.
If thyroidectomy for thyroid cancer was performed, radioactive iodine will be used to destroy the remaining tissue. After the thyroidectomy for thyroid cancer a thyroid-stimulating hormone suppression therapy will be performed in order to reduce its level in the body, preventing the increase of any malignant cells.

Home Treatment

Most thyroid nodules are benign and many of them do not require treatment.
If surgery was performed in order to excise the thyroid gland, it is important to:
- receive medication at the same time every day;
- receive the indicated dose: in case you missed a dose, do not double it on the second day;
- consult your doctor if you experience symptoms of hyperthyroidism as nervousness, tachycardia, more abundant sweating and weight loss;
- consult your doctor if you experience symptoms of hypothyroidism such as fatigue, unexplained feeling of cold and weight gain;
- inform the doctor or the pharmacist about any medication you are taking, in order to prevent the interaction with thyroid medication.
If a treatment with radioactive iodine was taken, consult a specialist when:
- you have a sore throat, which may represent an increase of the thyroid;
- you have symptoms of hypothyroidism, such as fatigue, unmotivated feeling of cold, and weight gain.
Thyroid nodules can not be prevented. It was not clarified yet the need of regular testing for people without risk factors and without the presence of the symptoms of hyperthyroidism. The need for testing will be discussed with your doctor.


Most thyroid cancers grow and disseminate so slowly, that surgery can be postponed for a short period of time, if you have a nodule that does not cause symptoms. If you choose to postpone surgery, the thyroid nodule should be examined regularly by an endocrinologist. Sometimes, thyroid nodules are treated by thyroid-stimulating hormone suppression therapy (levohyroxin) in order to stop the body producing this hormone and prevent growth of the thyroid gland.
This therapy is recommended if:
- Health does not allow surgery for a nodule which is suspected to be malignant;
- There has been an excision of multiple nodules. The suppression therapy is sometimes used to prevent the recurrence of nodules.
 Medication Choices
The thyroid-stimulating hormone suppression therapy is done with:
- Levothyroxine sodium or
- Liothyronine sodium.
The way of action of the suppression therapy on the benign nodules is not fully elucidated. It is recommended to consult a doctor about the suppression therapy, if a benign thyroid nodule exists.
The suppression of the thyroid-stimulating hormone may increase the risk of cardiac or skeletal problems, especially if this pathology existed before. If you have heart diseases, this therapy may aggravate chest pain or heart rhythm disorders. It also increases the risk of stroke. If you have osteoporosis, hormone suppression may worsen the demineralization of bones.
The suppression of the thyroid-stimulating hormone, even in small doses, often causes hyperthyroidism, especially if there are multiple nodules (multinodular goiter). Therefore, regular checkups to a specialist will be done for dose adjustment and to prevent hyperthyroidism. If a nodule is benign, but it produces an excess of hormones, causing hyperthyroidism, antithyroid medications must be used before the treatment with radioactive iodine.

Surgical treatment

Surgical excision is recommended for cystic nodules that recur, especially for those bigger than 4.1 centimeters in diameter. Hypothyroidism occurs in about 10% of patients in a period of 5 years after the treatment with radioactive iodine. Thus, thyroid hormone levels will be reviewed regularly after therapy.
It is the best treatment for thyroid nodules which are:
- Malignant (cancerous);
- Suspected to be malignant;
- Benign but large enough to interfere with breathing and swallowing;
People who develop thyroid nodules after radioactive therapy of the head, neck or chest will most likely need surgery because the risk of developing thyroid cancer is higher. However, most nodules in irradiated people are benign.
Surgical options
The most used method is thyroidectomy.

Other treatments

Other treatment options for thyroid nodules is the fine needle aspiration and radioactive iodine. During aspiration, the endocrinologist uses a small needle to drain fluid from the nodule (cystic nodule). Some cysts do not recur after drainage. However, most of them are recurrent. If the nodule returns after being drained once or two times, it must be excised surgically. The radioactive iodine is used to treat hyperthyroidism in people with benign nodules.




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