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Volume 39: Issue 2: 2009




Nodular  thyroid  disease  is  common.  Ultrasound  examination  of  the neck  for  a  variety  of  reasons  has  revealed  a  linear  increase  in  the  prevalence  of thyroid nodules from negligible at 15 years to 50% by the age of 60. Only 10% of these nodules are palpable by experienced examiners. Conversely, 50% of patients referred to a thyroid clinic with an apparently solitary thyroid nodule will be found to have a multinodular goitre. In the absence of marked asymmetry, rapid growth or  an  obvious ‘cold’  area  on  isotope  imaging,  multinodular  goitre  is,  for  practical purposes,  a  benign  condition  that  may  be  associated  with  hyperthyroidism  at presentation or in future years. On the other hand, a solitary palpable nodule may be malignant and the issue for the clinician is to identify the 5% that are malignant (usually  papillary  or  follicular  carcinomas)  by  using  a  combination  of  clinical assessment,  imaging,  thyroid  function  tests  and  cytology.  Ultrasound-guided  fine needle  aspiration  of  impalpable  thyroid  nodules  identified  by  imaging  has demonstrated  that  malignancy  is  as  common  as  in  palpable  solitary  nodules. Although  the  natural  history  of  these  thyroid  incidentalomas  in  an  ageing  population  is  not  known,  growth  is  likely  to  be  slow  and,  in  the  UK  at  least,  it  is  not common practice to adopt an aggressive policy of investigation and treatment.