Clinical Case Discussion: Solitary Thyroid Nodule

🩺 Clinical Case Discussion : Solitary Thyroid Nodule

Today, we'll have a clinical case discussion on a very common ENT presentation: Solitary Thyroid Nodule (STN).

This case discussion format will be helpful for both undergraduates and postgraduates.

We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.

📋 Patient History

Patient Demographics:

• Age: 36 year old female
• Residence: Mumbai
• Occupation: Homemaker

Chief Complaint:

• Swelling in front of the neck for 3 years.

📜 History of Present Illness

• Onset: Insidious, noticed 3 years ago.
• Progression: Gradually progressive, from ~2×2 cm to ~4×4 cm.
• Nature: Painless swelling, midline anterior neck.
• Pattern: Slowly progressive, no sudden changes.

Gradual progression → Suggests benign swelling.

What does Rapid increase VS Sudden increase in size of Thyroid swelling indicate?

❌ Negative History & Its Significance

🧬 Past, Family, Personal & Menstrual History

• Past Medical: No thyroid medication use, no prior surgeries.
• Drug history: No use of amiodarone, lithium, interferons, etc.
• Family History: No thyroid malignancy / MEN syndrome features.
• Personal History: Normal appetite, sleep, diet. No addictions.
• Menstrual/Obstetric History: Normal cycles, 2 healthy children.

What are the different drug history relevant to thyroid swelling? Why is it important?

What is MEN Syndrome? Which one is associated with Thyroid cancer and what are the features you see in it?

What are the genes involved in MEN Syndrome?

What is the importance of taking Menstrual history in a thyroid case?

What are the clinical features of Hypothyroidism?

What are the clinical features of Hyperthyroidism?

What is difference between Hyperthyroidism and Thyrotoxicosis?

🔬 Clinical Examination Findings

General & Systemic Examination: Normal.

Local Neck Examination:

• Inspection:

  • Single globular swelling, anterior midline (4×4 cm).
  • Extent: Below thyroid cartilage to 2 cm above sternal notch.
  • Moves with deglutition, not with tongue protrusion.
  • Skin normal, no scars/sinuses/pulsations/veins.
  • Trachea midline.
  • Pemberton’s sign negative.

• Palpation:

  • Firm, smooth, well-defined margins.
  • Non-tender, mobile in vertical & horizontal planes.
  • Lower border palpable.
  • Skin pinchable.
  • No bruit, no cervical lymphadenopathy.

• Percussion: Resonant over manubrium sterni → no retrosternal extension.

• Auscultation: No bruit.

• Carotids: Palpable bilaterally (Berry’s sign negative).

What are the neck swellings that move with deglutition?

What is a neck swelling that move with protrusion of tongue?

When do you see visible pulsations in Thyroid swelling?

When do you see Engorged Veins in Thyroid swelling?

What is Pemberton sign? How do you elicit it? What is the mechanism behind it? Name some condiitons where you see it.

Why do Thyroid swellings grow downwards, and not up?

What are the different Methods of Thyroid Palpation?

What is Thyroid paradox?

Where should you auscultate for bruit in a thyroid swelling? Why?

What is Berry's sign?

📝 Case Summary

A 36-year-old female presents with a solitary, midline, anterior neck swelling for 3 years.

• Swelling is firm, mobile, smooth-surfaced, moves with deglutition but not tongue protrusion, and has no pressure symptoms.
• No clinical features of thyroid dysfunction (clinically euthyroid).
• No lymphadenopathy.

🩺 Provisional Diagnosis

Solitary Thyroid Nodule, Left Lobe — Probably Benign, Clinically Euthyroid.

What are the points in favour of your diagnosis?

What are the Points to note in Provisional Diagnosis?

What is the Differential Diagnosis of Solitary Thyroid Nodule?

What is Dominant nodule in Multinodular Goiter?

What is Lateral Aberrant Thyroid?

What is the Most common site of nodule in Thyroid?

🏨 Management Plan

Management always consists of two parts: Investigation and Treatment.

Investigations

1. Thyroid Function Tests (TFTs): To confirm euthyroid / hypo / hyperthyroid status.

2. Ultrasound Neck (First-line imaging):

   • Confirm thyroid origin, size, solid/cystic, vascularity.
   • Look for malignant features → hypoechoic, taller-than-wide, microcalcifications.
   • Assess for cervical lymph nodes.

3. FNAC (Gold Standard): Report via Bethesda system.

   • Cannot distinguish follicular adenoma vs carcinoma.

4. Laryngoscopy: To assess vocal cord mobility (mandatory pre-op).

5. Other (selected cases):

   • Radionuclide scan (only if TSH low → hot vs cold nodule).
   • CT/MRI (retrosternal goiter, tracheal compression).
   • Antibody tests (Hashimoto’s suspected).

What is TIRADS?

What is Bethesda System for Reporting Thyroid Cytopathology?

Treatment - Left Hemithyroidectomy under General Anesthesia

What are the Surgical Indications in Solitary Thyroid Nodule?

What are the Steps of Hemithyroidectomy?

What are the Complications of Thyroidectomy?

✅ Final Takeaway:

This case is a benign solitary thyroid nodule in a clinically euthyroid young female, most likely managed by hemithyroidectomy with excellent prognosis.