GPs are often the first line of diagnosis for thyroid nodules. While most nodules are benign, when is further investigation needed? Through an in-depth case vignette, we share insights on what to look out for, how to investigate and manage, and when to refer.
A 40-year-old lady with no past medical history presents with a two-week history of a right anterior neck lump. The mass has not increased in size and she has no other symptoms such as hoarseness or dysphagia.
What else would you do?
On further questioning, she notes that her mother had a history of thyroid cancer with surgery performed many years ago. She is clinically euthyroid. On examination, a 2 cm right thyroid nodule is palpated. This appears well circumscribed, firm and moves with swallowing. There is no cervical lymphadenopathy. She is very anxious about this nodule and asks if she has cancer.
What can you tell her?
She agrees to further workup. What investigations should be performed?
You can perform:
You decide to perform the thyroid panel and neck ultrasound and the results return as:
Based on these suspicious results, you refer her to the SGH Otorhinolaryngology - Head & Neck Surgery specialist outpatient clinic.
What are other possible reasons for referral?
What patients can you manage without referral
at this point?
The patient is seen in the SGH Otorhinolaryngology
- Head & Neck Surgery specialist outpatient clinic
and ultrasound guided FNA is performed. The results
return as suspicious for papillary thyroid cancer and
she is offered a hemithyroidectomy versus a total
What are the pros and cons of hemithyroidectomy
versus total thyroidectomy?
In tumours less than 4 cm, hemithyroidectomy has
been found to have excellent survival in properly
selected low- to intermediate-risk (with no
extrathyroidal extension or lymph node metastases)
patients. While there is a slightly higher risk of
recurrence with hemithyroidectomies, salvage
therapy is highly effective.
Total thyroidectomy carries increased risk of
recurrent laryngeal nerve palsy and bilateral
recurrent laryngeal nerve palsy (which may require a
tracheostomy). Also, there is a risk of hypocalcaemia
and there is a need for lifelong thyroxine replacement
(as opposed to no risk of hypocalcaemia and 25%
risk of requiring thyroxine supplementation for
The patient decides on a total thyroidectomy and enquires about minimally invasive options that she has found while doing an online search.
What can you tell her about this?
The patient undergoes a total thyroidectomy uneventfully. Postoperatively her calcium levels are normal and parathyroid hormone level is at the lower range of normal. By postoperative day (POD) three, her calcium levels are noted to be stable and she is discharged home with a surgical drain, with advice on how to care for the drain.
Scenario 1:She presents to your clinic the day after discharge and her drain bottle has lost suction. What can you do?
Scenario 2:She presents to your clinic the day after discharge complaining of perioral numbness and tingling in her hands and feet. What should you do?
Histology results return as a 1.5 cm papillary thyroid carcinoma with no lymph node involvement. She is thus staged as a T1N0 papillary thyroid carcinoma and she is maintained on 100 mcg thyroxine.
How do we follow her up?
This may range from < 0.1 in high-risk patients to 0.5-2.0 mU/L in low-risk patients.
She remains well for 5 years with persistently low Tg levels and no evidence of disease on neck ultrasound. She is keen for discharge from the specialist clinic to be followed up under your care.
How can you monitor her?
Dr Kimberley Kiong is a Consultant at the Singapore General Hospital Department of Otorhinolaryngology - Head & Neck Surgery, and the Sengkang General Hospital Department of Otolaryngology (ENT). She is also Consultant with the SingHealth Duke-NUS Head & Neck Centre, seeing general ear, nose and throat (ENT) cases as well as thyroid and head and neck tumours.
Dr Kiong completed her medical degree at the National University of Singapore, Yong Loo Lin School of Medicine in 2011 and finished her ENT specialist training under the SingHealth Residency Program in 2017. During this time, she has published several papers and received the Outstanding Resident Award on multiple occasions.
Dr Kiong has completed a prestigious advanced fellowship training at the MD Anderson Cancer Center in Houston, USA, and is currently specialised in Head and Neck Cancer Surgery. Her specific interests include endoscopic skull base surgery for tumours and transoral robotic surgery.
Dr Anna See graduated from the National University of Singapore (NUS), Yong Loo Lin School of Medicine in 2012. She completed her membership examination of the Royal College of Surgeons of Edinburgh (Surgery) in 2014, and obtained her Master of Medicine (ENT) from NUS in 2015. She became a certified ENT specialist in 2018 upon completion of her ENT residency training in Singapore.
Her main interests are in the treatment of head and neck cancers and thyroid lesions. Her practice also covers general adult ENT conditions. Apart from clinical medicine, she has a keen interest in research of head and neck cancers and has presented in various regional and international conferences.
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