Thyroid History-Taking: A Surgical Approach

1. PRESENTING COMPLAINT

• Nature of the swelling/lump in the neck — when did the patient first notice it?
• Site — anterior midline, lateral neck, or substernal?
• Onset — sudden or gradual?
• Duration — days, weeks, months, years?
• Rate of growth — slow and stable vs. rapid enlargement

  A rapidly growing mass raises suspicion for thyroid lymphoma or anaplastic thyroid carcinoma (ATC); a stable nodule over years is less suspicious for malignancy.

• Pain — present or absent?

  Neck/throat pain is more commonly associated with hemorrhage into a benign nodule; it is rarely a feature of carcinoma.

2. HISTORY OF PRESENTING ILLNESS — SYSTEMIC SYMPTOMS

A. Mechanical / Compressive Symptoms (suggest large or invasive lesion)

• Dysphagia — difficulty swallowing (esophageal compression)?
• Dysphonia / Hoarseness — voice change (recurrent laryngeal nerve [RLN] involvement)?

  Vocal cord paralysis can be clinically occult; it heightens suspicion for malignancy even in the absence of previous surgery.

• Dyspnea / Stridor — tracheal compression?
• Neck pain or tightness
• Pemberton's sign — arm elevation causing facial flushing, venous engorgement, or subjective respiratory distress (suggests substernal goiter with thoracic inlet obstruction)

B. Thyroid Functional Symptoms

3. PAST MEDICAL & SURGICAL HISTORY

Previous Thyroid-Related History

• Known thyroid nodule(s) or goitre — when diagnosed? Any change in size?
• Previous thyroid biopsy (FNA) — what was the result?
• Previous thyroid surgery — type, date, reason, and outcome?
• Previous diagnosis of thyroiditis (e.g., Hashimoto's, de Quervain's), Graves' disease, or hypo/hyperthyroidism?

  A history of transient hypothyroidism requiring exogenous thyroid hormone should alert the clinician to the possibility of thyroiditis.

Previous Head & Neck Surgery or Radiation

• Any head and neck surgery prior to presentation?

  Triggers pre-operative laryngoscopy or videostroboscopy to assess RLN function before proceeding.

• History of therapeutic radiation to the head, neck, or mediastinum (e.g., mantle radiation for Hodgkin's lymphoma, cranial radiation for childhood leukaemia, past radiation for acne/tonsillar hypertrophy)?

  Radiation exposure — particularly before age 18 — is the only established environmental risk factor for papillary thyroid carcinoma (PTC). Up to 40% of patients with a thyroid nodule and prior radiation history have thyroid cancer.

• Environmental/fallout radiation exposure (e.g., Chernobyl)?

General Medical History

• Autoimmune diseases (Type 1 DM, Addison's disease, rheumatoid arthritis — associated with thyroid autoimmunity)?
• Atrial fibrillation or other cardiac disease (thyrotoxicosis can precipitate)?
• Pregnancy or postpartum period (postpartum thyroiditis)?

4. DRUG HISTORY

• Amiodarone — can induce both hyper- and hypothyroidism
• Lithium — associated with hypothyroidism and goitre
• NSAIDs, phenytoin, carbamazepine, furosemide, aspirin, oral contraceptive pills — alter thyroid binding protein levels, affecting total T3/T4 interpretation
• Current or previous thyroid hormone replacement (levothyroxine) or antithyroid drugs (carbimazole, propylthiouracil)?
• Iodine-containing supplements or radiological contrast use?
• Immunotherapy/checkpoint inhibitors — increasingly recognised cause of thyroiditis

5. FAMILY HISTORY

• Thyroid cancer in first-degree relatives (especially papillary thyroid cancer in ≥2 first-degree relatives)
• Medullary thyroid carcinoma (MTC) — associated with MEN 2A and 2B
• Pheochromocytoma or hyperparathyroidism — should raise suspicion for Multiple Endocrine Neoplasia type 2 (MEN 2)
• Genetic syndromes associated with thyroid cancer:
  • MEN 2A/2B (RET mutation) — MTC + phaeochromocytoma ± hyperparathyroidism
  • Cowden syndrome (PTEN mutation) — follicular thyroid cancer
  • Familial adenomatous polyposis (FAP) / Gardner syndrome — papillary thyroid cancer
  • Carney complex, Werner syndrome, DICER1 syndrome
• Family history of autoimmune thyroid disease (Graves', Hashimoto's)
• Family history of goitre

6. SOCIAL HISTORY

• Dietary iodine intake — iodine-deficient diet or area of endemicity (endemic goitre)?
• Occupation — radiation exposure at work (radiology, nuclear medicine, mining)?
• Smoking — associated with Graves' ophthalmopathy and nodular goitre
• Alcohol
• Place of origin / travel — endemic goitre regions?
• Functional status — how do symptoms affect daily activities?

7. REVIEW OF SYSTEMS (Surgical Red Flags for Malignancy)

8. SUMMARY OF KEY POINTS TO FILL IN (Structured Proforma)

THYROID HISTORY SHEET
─────────────────────────────────────────
1. PRESENTING COMPLAINT
   □ Swelling – site / onset / duration / rate of growth
   □ Pain – present / absent / character

2. COMPRESSIVE SYMPTOMS
   □ Dysphagia       □ Dysphonia/hoarseness
   □ Dyspnoea/stridor   □ Pemberton's sign elicited?

3. FUNCTIONAL STATUS
   □ Hyperthyroid symptoms: palpitations / tremor / weight loss /
     heat intolerance / diarrhoea / irritability / insomnia
   □ Hypothyroid symptoms: fatigue / weight gain / constipation /
     cold intolerance / dry skin / depression / menorrhagia
   □ Euthyroid (asymptomatic)

4. PAST HISTORY
   □ Previous thyroid disease (type + treatment)
   □ Previous thyroid surgery / biopsy (result)
   □ Head & neck surgery / radiation (type / age / dose if known)
   □ Autoimmune disease
   □ Cardiac history (AF / IHD)
   □ Pregnancy / postpartum

5. MEDICATIONS
   □ Amiodarone   □ Lithium   □ Levothyroxine
   □ Antithyroid drugs   □ OCP / NSAIDs / anticonvulsants
   □ Immunotherapy

6. FAMILY HISTORY
   □ Thyroid cancer (type / relative)
   □ MTC / phaeochromocytoma / hyperparathyroidism → MEN 2?
   □ Cowden / FAP / Gardner / Carney complex
   □ Autoimmune thyroid disease / goitre

7. SOCIAL HISTORY
   □ Diet (iodine intake)   □ Occupation (radiation exposure)
   □ Smoking / alcohol
   □ Residence / travel (endemic area)
   □ Functional impact of symptoms

8. RED FLAGS CHECKLIST (malignancy risk)
   □ Age < 20 or > 65
   □ Male sex
   □ Rapid growth
   □ Radiation history (childhood)
   □ Family history of thyroid cancer / MEN 2
   □ Vocal cord palsy / hoarseness
   □ Fixed mass / lymphadenopathy

Sources

• Mulholland & Greenfield's Surgery: Scientific Principles and Practice, 7e — Chapter 75: Clinical Evaluation of the Patient with a Thyroid Disorder
• Cummings Otolaryngology Head and Neck Surgery — Clinical Assessment: History and Physical Examination
• Schwartz's Principles of Surgery, 11e — Solitary Thyroid Nodule
• Harrison's Principles of Internal Medicine, 22e (2025) — Table 397-2: Risk Factors for Thyroid Carcinoma