Benign, non-functioning thyroid nodules

How are benign nodules detected?

Thyroid nodules are common, and by age 60 almost ½ of normal healthy people have nodules that can either be felt in the neck or found with an imaging test like an ultrasound. The majority (>90%) of all thyroid nodules are non-cancerous. They are more common in women than men and more common as you age. Most nodules cannot be felt by you or your physician and usually go unnoticed until they are found by accident on an imaging test done for another reason, such as a CT scan or MRI of the neck or chest. Others can be easily felt and are sometimes large enough to cause symptoms, including choking, trouble swallowing, or rarely, hoarseness of the voice. However, the majority of nodules do not cause these symptoms.

What is the usual evaluation for a thyroid nodule?
Once a thyroid nodule is detected, your doctor will ask questions to determine if the nodule is causing symptoms. Examination of your neck is important to determine the relationship of the nodule to the surrounding structures like the trachea (windpipe) or esophagus (the swallowing tube from your throat to your stomach). You will also be assessed for enlarged lymph nodes in the neck, which may need to be evaluated further.
Thyroid tests like a thyroid stimulating hormone (TSH) level will be checked to determine whether the nodule may be producing too much thyroid hormone. Nodules that make thyroid hormone are also known as “toxic”, “autonomous” or “hyperfunctioning” thyroid nodules and require additional evaluation as described below under toxic thyroid nodules.
 A sonogram of the thyroid is the best test to evaluate thyroid nodule structure. This gives information about the size and appearance of the nodule(s)  and can help determine how likely a nodule is to be cancerous.
Based on nodule size and appearance, along with other factors such as age and family history of thyroid cancer, a fine-needle aspiration biopsy (FNA) may be recommended. FNA is a safe office procedure that is typically very easily tolerated. FNA can help determine if the nodule is benign or worrisome for cancer.

When do benign nodules require treatment?

Most benign thyroid nodules do not require treatment if they are benign by FNA cytology, do not cause symptoms, and are not cosmetically bothersome. Treatment of benign thyroid nodules should be considered in the following circumstances:

Nodules that cause symptoms.

Some nodules, especially when they are greater than 2-3 cm in size, can cause uncomfortable symptoms in the neck. These include a choking sensation, which may be worse when lying down, or trouble swallowing. Hoarseness of the voice is less common but can also happen.  There can be other reasons for these symptoms however so your doctor will help to evaluate your symptoms completely.

Some nodules, especially when they are greater than 2-3 cm in size, can cause uncomfortable symptoms in the neck. These include a choking sensation, which may be worse when lying down, or trouble swallowing. Hoarseness of the voice is less common but can also happen.  There can be other reasons for these symptoms however so your doctor will help to evaluate your symptoms completely.

Nodules that are cosmetically bothersome.

Depending on the size of the nodule and its location within the thyroid, some nodules can be visible to you or others. Some patients find this to be bothersome and treatment is also reasonable when this occurs.

Nodules that produce too much thyroid hormone.

If a nodule causes hyperthyroidism (overactive thyroid) by releasing too much thyroid hormone, treatment may be recommended.

What are the treatment options for benign nodules that do cause symptoms?
There are several treatment options for benign nodules. The treatment of choice depends on several factors, and therefore there is no ‘one size fits all’ approach. Rather, you and your physician will select the option that is best for you.
Observation is an option but it is best used for benign nodules that do not cause symptoms, are not cosmetically bothersome, and do not release excessive amounts of thyroid hormone.
Surgery to remove half of the thyroid gland (lobectomy or hemithyroidectomy) or the whole thyroid gland (total thyroidectomy) is an effective option to resolve symptoms or to stop the release of excessive thyroid hormone. However, this requires general anesthesia as well as recovery after surgery and leaves a small permanent scar usually located on the front of the neck.

If the entire thyroid is removed surgically, daily lifelong medication to replace thyroid hormone will be needed.  Even when only half the thyroid is removed, lifelong thyroid hormone replacement may still be needed by some patients.

Radiofrequency ablation (RFA) is an alternative to surgery for benign thyroid nodules that need treatment. This is done usually in the office under local anesthesia. There is no scar from the procedure, thyroid hormone replacement is typically not needed after RFA, and recovery is typically faster. But just like surgery, RFA is best performed by an experienced provider.

Other minimally invasive treatments for thyroid nodules (like RFA) include laser ablation, microwave ablation, ethanol ablation, and thyroid artery embolization