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A 70 year old lady with swelling over front and right side of neck which moves on degglutiotion, it's painless, soft, mobile, nontender. How to evaluate the case and mange

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thyroid nodule AND ultrasonography

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2025 ATA thyroid nodule evaluation ultrasound FNA guidelines

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https://pmc.ncbi.nlm.nih.gov/articles/PMC12821139

This is most suggestive of a thyroid swelling, likely a right thyroid nodule or dominant nodule in multinodular goitre, because it moves on swallowing. However, in a 70-year-old, malignancy must be actively excluded even if it is painless, soft, mobile, and non-tender.

1. First assess for urgency

Arrange early review by an ENT/head-and-neck surgeon or endocrine surgeon. Seek urgent assessment if there is:
  • Rapid enlargement
  • New hoarseness or change in voice
  • Dysphagia, choking, dyspnoea, stridor, or a feeling of pressure when lying down
  • Hard, fixed, irregular swelling
  • Cervical lymph nodes
  • Unexplained weight loss
  • Prior neck irradiation or family history of thyroid cancer
Age over 70, hoarseness, dysphagia, a firm/fixed nodule, large size, and cervical lymphadenopathy are clinical features that raise concern for thyroid cancer. Sabiston Textbook of Surgery, p. 1502.

2. Clinical evaluation

History

Ask about:
  • Duration and rate of growth
  • Pressure symptoms: dysphagia, dyspnoea, stridor, cough, positional breathlessness
  • Voice change
  • Pain, fever, recent infection
  • Symptoms of hyperthyroidism: palpitations, tremor, heat intolerance, weight loss
  • Symptoms of hypothyroidism
  • Previous irradiation to head/neck
  • Personal/family history of thyroid cancer, MEN2, or thyroid disease
  • Drugs, especially amiodarone and lithium

Examination

  • Inspect and palpate the thyroid: size in cm, side, surface, consistency, margins, mobility, retrosternal extension.
  • Check whether the swelling moves with tongue protrusion. A thyroglossal duct cyst typically moves both with swallowing and tongue protrusion, whereas a thyroid swelling usually moves chiefly with swallowing.
  • Examine all cervical lymph-node levels.
  • Assess for tracheal deviation/compression.
  • Perform a voice assessment. If voice is altered or surgery is being considered, flexible laryngoscopy is appropriate to check vocal-cord movement.

3. Investigations

Essential first-line tests

  1. Thyroid function tests
    • TSH first
    • Free T4, and T3 if TSH is low
  2. High-resolution ultrasound of thyroid and neck lymph nodes Request a structured report using ACR TI-RADS or another validated sonographic risk system. It should document:
    • Nodule size in three dimensions
    • Solid versus cystic composition
    • Echogenicity
    • Margins
    • Calcifications or punctate echogenic foci
    • Taller-than-wide shape
    • Extrathyroidal extension
    • Contralateral nodules
    • Suspicious cervical nodes
Ultrasound confirms whether the palpable mass is thyroidal, identifies additional nodules, assesses lymph nodes, and determines whether FNA is needed. Harrison’s Principles of Internal Medicine, 22e, p. 3091.
  1. Ultrasound-guided fine-needle aspiration cytology, if indicated
    • Do FNA of nodules meeting ultrasound risk-and-size criteria.
    • Aspirate any suspicious cervical lymph node as well, sometimes with thyroglobulin washout.
    • Cytology should be reported using the Bethesda system.
FNA is the preferred diagnostic test for a suspicious thyroid nodule when performed with ultrasound guidance and interpreted by experienced cytopathology services. Harrison’s Principles of Internal Medicine, 22e, p. 3091.

When to do radionuclide thyroid scan

If TSH is suppressed, obtain a technetium or radioiodine uptake scan before FNA to identify a hyperfunctioning ("hot") nodule. Hot nodules are very rarely malignant and generally do not require FNA. Harrison’s Principles of Internal Medicine, 22e, p. 3091.

Tests that are not routine

  • Serum thyroglobulin is not useful for initial diagnosis of a thyroid nodule.
  • Calcitonin is not routinely required, but consider it if there is a family history of MEN2/medullary thyroid carcinoma or cytology/clinical findings suggest it.
  • CT or MRI neck/chest is not routine. Use it for a large goitre, substernal extension, airway compression, invasive disease, bulky nodes, or when ultrasound is inadequate.

4. Management according to results

FindingUsual management
Benign ultrasound pattern and small noduleReassure and ultrasound surveillance
Benign FNAClinical and ultrasound follow-up; operate only for compressive symptoms, growth, cosmetic concern, or uncertainty
Simple/mostly cystic benign noduleAspiration if symptomatic; recurrence may be managed with repeat aspiration, ethanol/thermal ablation in selected cases, or surgery
Toxic/hot nodule with low TSHTreat hyperthyroidism with endocrinology input; options include radioiodine or surgery, depending on size, symptoms, and patient factors
Indeterminate Bethesda III/IV FNARepeat FNA, molecular testing where available, or diagnostic hemithyroidectomy depending on risk and local expertise
Suspicious/malignant FNA, suspicious nodes, compressive symptoms, or significant retrosternal goitreRefer for definitive thyroid surgery planning
For a one-sided benign dominant nodule, hemithyroidectomy may be suitable if surgery is needed. Total thyroidectomy is more often considered for bilateral multinodular disease, proven cancer requiring it, or selected large/compressive goitres. Surgery is indicated for compressive symptoms, substernal extension, suspicious/malignant nodules, or patient preference after counselling. Sabiston Textbook of Surgery, p. 1502.

Practical plan for this patient

  1. Refer promptly to ENT/endocrine surgery.
  2. Order TSH, free T4, and ultrasound thyroid with cervical lymph-node mapping and TI-RADS score.
  3. If TSH is low, perform thyroid scintigraphy.
  4. If ultrasound indicates, obtain US-guided FNA.
  5. Decide surveillance versus surgery from the cytology, ultrasound risk, nodule size, symptoms, and surgical fitness.
Her painless, mobile nature is reassuring but does not rule out cancer. The key next investigation is an expert thyroid ultrasound followed, where appropriate, by US-guided FNA.
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