1. History to ask

Nodule history

• When first noticed? Any recent rapid increase in size?
• Neck pain or tenderness?
• Previous neck swelling, thyroid disease, or thyroid surgery?
• Symptoms of local compression/invasion:
  • Dysphagia or choking
  • Dyspnea, stridor, cough, orthopnea
  • Voice change or hoarseness
  • Neck pressure
• Constitutional symptoms: unexplained weight loss, anorexia, fever, night sweats.

Thyroid functional symptoms

• Hyperthyroidism: palpitations, heat intolerance, tremor, sweating, weight loss, diarrhea, anxiety.
• Hypothyroidism: fatigue, cold intolerance, weight gain, constipation, dry skin, hair loss.

Malignancy risk factors

• Childhood or adolescent head/neck irradiation, total-body irradiation, or nuclear-fallout exposure.
• Family history of thyroid cancer, especially:
  • Medullary thyroid carcinoma
  • MEN2
  • Familial papillary thyroid carcinoma
  • Cowden/PTEN syndrome, FAP, Carney complex.
• Prior thyroid cancer or other malignancy.
• Ask about relatives with pheochromocytoma, hyperparathyroidism, mucosal neuromas, or early thyroid cancer if considering MEN2/medullary carcinoma.

2. Physical examination

Thyroid and neck

• Inspect the neck at rest and with swallowing.
• Palpate the thyroid:
  • Site, size, consistency, surface, tenderness
  • Solitary versus multinodular gland
  • Mobility with deglutition
  • Fixity to skin, strap muscles, or trachea
  • Retrosternal extension, including Pemberton sign if clinically indicated.
• Palpate all cervical nodal groups:
  • Central compartment: level VI
  • Lateral neck: levels II to V
  • Supraclavicular nodes
  • Note size, firmness, fixation, and laterality.
• Assess for tracheal deviation/compression.

Voice and larynx

• Listen for hoarseness.
• Assess vocal quality and cough.
• Do flexible laryngoscopy to document vocal-cord mobility, particularly if there is voice change, suspected invasive disease, or before thyroid surgery.

General examination

• Vital signs.
• Signs of hyperthyroidism: tachycardia/atrial fibrillation, tremor, warm moist hands, hyperreflexia, eye signs.
• Signs of hypothyroidism: bradycardia, dry skin, delayed reflex relaxation.
• Look for features of MEN2 if history suggests it.

3. Laboratory tests

Essential initial tests

1. Serum TSH
2. If TSH is abnormal: free T4, with or without free T3.

Selected tests

• Anti-TPO antibodies if thyroiditis is suspected clinically or on ultrasound.
• Serum calcitonin, with or without CEA, only if there is suspicion of medullary thyroid carcinoma, MEN2, or a relevant family history.
• Do not request serum thyroglobulin to diagnose the nodule. It is nonspecific in an intact thyroid and is more useful after thyroid-cancer treatment for surveillance.
• Preoperative tests if surgery is planned: CBC, renal function/electrolytes, calcium/albumin, coagulation profile as locally required.

4. Diagnosis and confirmation

Working diagnosis

• Nodule is 1.5 × 2.5 cm.
• Hypoechoic.
• Ill-defined margins.
• Microcalcifications, which may represent psammoma bodies in papillary carcinoma.
• Ipsilateral level III lymph node.
• Reported as TI-RADS 4.

Confirmatory next step

• Ultrasound-guided FNA of the thyroid nodule, with cytology reported using the Bethesda system.
• Ultrasound-guided FNA of the suspicious level III lymph node for cytology.
• Send thyroglobulin washout from the lymph-node FNA if available, as an adjunct to establish metastatic differentiated thyroid carcinoma.

Likely final diagnosis if FNA confirms it

Subsequent plan if cytology is malignant

• Refer to endocrine surgery/ENT multidisciplinary team.
• Formal preoperative neck ultrasound mapping of central and lateral compartments.
• Consider contrast CT neck/chest only if bulky nodal disease, substernal extension, or invasion is suspected.
• Surgical extent depends on final cytology, tumor features, and nodal confirmation, but confirmed lateral nodal metastasis generally warrants thyroid surgery plus a therapeutic compartment-based lateral neck dissection, not simple removal of one node.

Case summary

Note: “Spongiform” usually suggests low risk, but hypoechogenicity, ill-defined margins, and microcalcifications are concerning findings. Clarify the official ultrasound description and obtain complete lymph-node morphology.

1. History

A. Present illness

• When was the neck mass first noticed?
• Has it increased in size, especially rapid recent growth?
• Any other neck lumps?
• Pain or tenderness? Sudden painful enlargement can suggest hemorrhage into a cyst.
• Dysphagia, odynophagia, choking, foreign-body sensation?
• Dyspnea, stridor, cough, orthopnea, or neck tightness?
• Hoarseness, voice fatigue, or aspiration while swallowing?
• Previous ultrasound, thyroid tests, FNA, or thyroid treatment?

B. Symptoms of thyroid dysfunction

• Palpitations, tremor, sweating, heat intolerance
• Anxiety, weight loss, increased bowel frequency
• Proximal muscle weakness

• Fatigue, cold intolerance, constipation
• Weight gain, dry skin, hair loss
• Slow thinking, depression, hoarse voice

C. Cancer risk factors

• Prior therapeutic radiation to the head, neck, or chest, particularly in childhood.
• Exposure to ionizing radiation or nuclear fallout.
• Family history of thyroid cancer.
• Family history of medullary thyroid carcinoma (MTC), MEN2, pheochromocytoma, or hyperparathyroidism.
• Family syndromes: FAP, Cowden/PTEN hamartoma syndrome, Carney complex.
• Previous malignancy or total-body irradiation.

D. Constitutional and systemic symptoms

• Unintentional weight loss
• Fever, drenching night sweats
• Loss of appetite

2. Physical examination

General examination

• Vital signs, body weight, nutritional status.
• Look for hyperthyroidism: tremor, tachycardia/atrial fibrillation, warm moist hands, hyperreflexia, lid lag.
• Look for hypothyroidism: dry skin, bradycardia, periorbital puffiness, delayed ankle reflex relaxation.

Local neck and thyroid examination

Inspection

• Inspect at rest and during swallowing.
• Assess for visible asymmetry, scars, venous engorgement, tracheal deviation, or skin involvement.

Palpation of thyroid

• Site: left/right lobe, isthmus.
• Size and number of nodules.
• Consistency: soft, firm, hard.
• Surface: smooth or irregular.
• Tenderness.
• Movement with deglutition.
• Mobility versus fixation to underlying structures.
• Retrosternal extension.
• Tracheal position.

Cervical lymph-node examination

• Central compartment, level VI
• Lateral neck, levels II-V
• Supraclavicular nodes

• Exact neck level, likely level III
• Size
• Firmness/hardness
• Mobility or fixation
• Tenderness
• Whether single or multiple

Voice and laryngeal assessment

• Assess voice quality and ask the patient to phonate.
• Perform flexible nasolaryngoscopy to assess vocal-cord mobility, especially before surgery or if any voice change is reported.

3. Diagnostic evaluation

A. Blood tests

Essential

1. Serum TSH
2. If TSH is abnormal: free T4 and, if needed, free T3.

Selective tests

• Anti-TPO antibody if autoimmune thyroiditis is clinically suspected.
• Serum calcitonin, with or without CEA, if there is clinical or family-history concern for MTC/MEN2.
• Do not routinely request serum thyroglobulin for initial diagnosis of a thyroid nodule.

B. Imaging

1. Dedicated high-resolution ultrasound of the whole thyroid and cervical lymph-node compartments
   • Document nodule composition, echogenicity, margins, calcifications, shape, vascularity, and extrathyroidal extension.
   • Examine central and bilateral lateral compartments.
   • For the level III node, document short-axis diameter, fatty hilum, shape, cystic change, calcifications, and peripheral vascularity.
2. Radionuclide thyroid scan only if TSH is low/suppressed.
3. Contrast CT neck and upper mediastinum only if there is suspected invasive disease, bulky nodal disease, retrosternal extension, or concern for tracheal/aerodigestive involvement. It is not routinely required in this currently non-compressive presentation.

C. Tissue diagnosis

Thyroid nodule

• Perform ultrasound-guided FNA of the 2.5 cm left thyroid nodule.
• Report cytology using the Bethesda system.

Level III lymph node

• If it has suspicious ultrasound morphology, perform ultrasound-guided FNA cytology of the lymph node.
• Add thyroglobulin measurement in the needle washout fluid if differentiated thyroid carcinoma is suspected.

4. Most likely diagnosis

Clinical diagnosis

Diagnosis after confirmation

5. Differential diagnosis

Immediate next step

Thyroid Nodule Workup Flowchart

PALPABLE THYROID NODULE OR INCIDENTAL THYROID NODULE
                           │
                           ▼
             HISTORY + PHYSICAL EXAMINATION
             - Growth rate, pain, compressive symptoms
             - Hoarseness/voice change
             - Childhood head/neck radiation
             - Family history: thyroid cancer, MEN2/MTC
             - Palpate thyroid and all cervical lymph-node levels
             - Assess vocal cords if voice change or preoperative
                           │
                           ▼
          SERUM TSH + DEDICATED NECK ULTRASOUND
          Ultrasound must assess:
          - Nodule size and TI-RADS/sonographic risk features
          - Both thyroid lobes
          - Central and lateral cervical lymph nodes
                           │
          ┌────────────────┴─────────────────┐
          ▼                                  ▼
     LOW/SUPPRESSED TSH                 NORMAL/HIGH TSH
          │                                  │
          ▼                                  ▼
 Radionuclide thyroid scan              Use ultrasound risk pattern
          │                              + nodule size to decide FNA
          │                                  │
   ┌──────┴────────┐                         │
   ▼               ▼                         ▼
"HOT" nodule    Nonfunctioning          DOES THE NODULE MEET
(hyperfunctioning)  nodule              FNA CRITERIA?
   │               │                         │
   ▼               └───────────────►         │
Treat as toxic                                │
nodule if indicated                    ┌──────┴──────────┐
and assess other                       ▼                 ▼
suspicious nodules              NO FNA CRITERIA    FNA CRITERIA MET
separately                            │                 │
                                      ▼                 ▼
                              Ultrasound follow-up   US-GUIDED FNA
                              interval based on      of thyroid nodule
                              TI-RADS/risk pattern   → Bethesda cytology
                                                        │
                                                        ▼
                         ┌─────────────────────────────────────────────────┐
                         │              BETHESDA RESULT                     │
                         └─────────────────────────────────────────────────┘
       │                 │                    │                  │         │
       ▼                 ▼                    ▼                  ▼         ▼
  I: Nondiagnostic   II: Benign          III/IV:             V: Suspicious VI: Malignant
                                        Indeterminate         for malignancy
       │                 │                    │                  │         │
       ▼                 ▼                    ▼                  ▼         ▼
 Repeat US-guided    US surveillance    Repeat FNA and/or    Surgical       Surgical
 FNA                 according to       molecular testing;   referral       referral
                     US risk pattern;   consider diagnostic  and staging    and staging
                     repeat only if     lobectomy based on
                     growth/new         clinical and US risk
                     suspicious feature

Parallel branch: suspicious lymph node

SUSPICIOUS CERVICAL LYMPH NODE ON EXAM OR ULTRASOUND
- Rounded shape
- Loss of fatty hilum
- Cystic change
- Microcalcifications
- Peripheral vascularity
- Hyperechogenicity
                         │
                         ▼
US-GUIDED FNA OF LYMPH NODE
+ Thyroglobulin washout if differentiated thyroid cancer is suspected
(+ Calcitonin washout if medullary thyroid carcinoma is suspected)
                         │
          ┌──────────────┴──────────────┐
          ▼                             ▼
  METASTATIC THYROID CANCER        BENIGN/NONDIAGNOSTIC
          │                             │
          ▼                             ▼
Preoperative neck mapping,         Repeat FNA or surveillance,
surgical/endocrine referral,       depending on morphology
and consider CT neck/chest
if bulky or invasive disease

Key FNA thresholds using ATA ultrasound pattern

Applied to your case

Papillary Thyroid Carcinoma: Diagnostic and Management Flowchart

SUSPICIOUS THYROID NODULE ± CERVICAL LYMPH NODE
                   │
                   ▼
HISTORY + PHYSICAL EXAMINATION
- Radiation exposure, family thyroid cancer/MEN2
- Rapid growth, dysphagia, dyspnea, hoarseness
- Thyroid examination and full cervical node examination
                   │
                   ▼
TSH + HIGH-RESOLUTION THYROID AND NECK ULTRASOUND
- Characterize thyroid nodule
- Map central and lateral cervical lymph nodes
                   │
                   ▼
US-GUIDED FNA OF:
- Suspicious thyroid nodule
- Any morphologically suspicious cervical lymph node
  + thyroglobulin washout from nodal aspirate
                   │
                   ▼
CYTOLOGY: PAPILLARY THYROID CARCINOMA
(Bethesda VI or malignant node cytology)
                   │
                   ▼
PREOPERATIVE STAGING
- Complete neck US mapping
- Assess vocal-cord mobility by laryngoscopy if dysphonia,
  prior neck surgery, posterior extension, or lateral nodal disease
- CT neck/chest with contrast if bulky nodes, invasion,
  retrosternal extension, or suspected distant disease
                   │
                   ▼
STRATIFY DISEASE

A. INTRATHYROIDAL, UNIFOCAL PTC, 1-4 cm
   No extrathyroidal extension, no nodal/distant metastasis (cN0M0)
                   │
                   ▼
THYROID LOBECTOMY may be adequate
                   │
                   ▼
Histology-directed risk assessment and surveillance
- Neck US
- TSH management
- Thyroglobulin trend if total thyroidectomy was done

B. TUMOR >4 cm, GROSS EXTRATHYROIDAL EXTENSION,
   BILATERAL/MULTIFOCAL DISEASE, OR DISTANT METASTASIS
                   │
                   ▼
TOTAL THYROIDECTOMY
                   │
                   ▼
Consider radioactive iodine (RAI) according to postoperative
risk stratification and iodine avidity
                   │
                   ▼
Levothyroxine with risk-adapted TSH suppression

C. CONFIRMED CENTRAL NODE METASTASIS (cN1a)
                   │
                   ▼
TOTAL THYROIDECTOMY OR APPROPRIATE THYROID RESECTION
+ THERAPEUTIC CENTRAL COMPARTMENT NECK DISSECTION
(Level VI ± upper VII)

D. CONFIRMED LATERAL NECK NODE METASTASIS (cN1b)
                   │
                   ▼
THYROIDECTOMY
+ THERAPEUTIC COMPARTMENT-ORIENTED LATERAL NECK DISSECTION
(usually levels II-V as indicated by nodal mapping)
± ipsilateral therapeutic central neck dissection
                   │
                   ▼
Postoperative risk assessment → consider RAI

Applied to this case

2.5 cm suspicious left thyroid nodule
+ 1.1 cm ipsilateral level III node
                   │
                   ▼
FNA thyroid nodule + FNA level III node with Tg washout
                   │
                   ▼
If PTC with metastatic level III node is confirmed:
Papillary thyroid carcinoma, cN1b
                   │
                   ▼
Preoperative full neck mapping + laryngoscopy
                   │
                   ▼
Thyroidectomy + therapeutic lateral neck dissection
and consideration of ipsilateral central neck dissection
                   │
                   ▼
Final histopathology → ATA recurrence-risk assessment,
RAI decision, levothyroxine/TSH target, surveillance

Key point