Indications for thyroid surgery and clinical suspicion of malignancy
THE CONTEXT
The decision to operate on a thyroid swelling depends primarily on neoplasia risk, with clinical findings and patient characteristics providing additional guidance.
Reasons to operate
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The main indication for operation is the risk of neoplasia, including follicular adenoma as well as malignant swellings.
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Removal of all follicular neoplasms is advocated because cytology seldom distinguishes follicular adenoma from carcinoma.
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Even with negative cytology, age, sex and swelling size may provide relative indications for surgery, particularly when a large swelling causes symptoms.
Clinical findings suggesting malignancy
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Hard texture alone is unreliable because tense cystic swellings may feel suspiciously hard.
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A hard, irregular swelling with apparent fixation is highly suspicious.
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Recurrent laryngeal nerve paralysis, suggested by hoarseness and a non-occlusive cough and confirmed by laryngoscopy, is almost pathognomonic of malignancy.
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Cervical lymphadenopathy along the internal jugular vein with a clinically suspicious thyroid swelling is almost diagnostic of papillary thyroid carcinoma.
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Most patients do not have these strongly suspicious clinical features.
Age and sex
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Thyroid carcinoma occurs about three times as often in women as in men, but a discrete thyroid swelling in a man is much more likely to be malignant than one in a woman.
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Carcinoma risk increases at either end of the age range.
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A discrete thyroid swelling in a teenager of either sex must be provisionally diagnosed as carcinoma.