Thyroid disorders are among the most common reasons patients are referred to an endocrine surgeon. The key to understanding how these conditions are assessed and managed lies in a simple but important distinction:
Is the problem structural or functional?
This classification helps determine whether surgery is needed and which investigations are most appropriate.
Two Broad Categories of Thyroid Disorders
1. Structural Disorders
These involve physical changes in the thyroid gland and are often the domain of surgical treatment. Examples include:
- Thyroid nodules or lesions
- Goitre (enlarged thyroid) – may be visible or extend behind the breastbone (retrosternal goitre)
- Thyroid cancers
- Multinodular goitre
When is surgery recommended?
- Thyroid cancers almost always require surgical removal.
- Suspicious nodules based on imaging or biopsy are typically resected to confirm or treat cancer.
- Benign nodules may also need removal if they are enlarging or causing pressure symptoms (difficulty swallowing, breathing issues, or voice changes).
- Large or retrosternal goitres that compress surrounding structures are best removed before complications arise.
2. Functional Disorders
These involve abnormal hormone production by the thyroid gland:
- Hyperthyroidism (overactive thyroid)
- Hypothyroidism (underactive thyroid)
Most functional disorders are managed by an endocrinologist. However, surgery plays a role in select cases of hyperthyroidism, particularly when:
- There is Graves’ disease with poor response to medical therapy
- There is a toxic multinodular goitre causing excess hormone production
What to Expect When Seeing an Endocrine Surgeon for a Thyroid Nodule
If you’re referred for a thyroid nodule, your consultation will usually follow a structured approach:
1. History Taking
We begin by understanding:
- When and how the nodule was discovered (routine scan, physical symptoms, etc.)
- Whether there are symptoms such as:
- Neck pain or discomfort
- Difficulty swallowing (dysphagia)
- Breathing difficulty (dyspnoea)
- Voice changes (dysphonia)
2. Clinical Examination
- Is the nodule palpable?
- Are there any enlarged neck lymph nodes?
- We assess the shape of your neck and your range of motion to anticipate surgical complexity (e.g. short/stout necks or limited extension may pose challenges).
3. Review of Investigations
Ultrasound of the Thyroid
This is the first-line imaging test. It gives a detailed view of the thyroid and any nodules. Nodules are assessed using the TIRADS scoring system, which helps estimate cancer risk and guides the need for biopsy. Cervical lymph nodes are also assessed.
TIRADS Summary:
| TIRADS Category | Risk of Malignancy | Biopsy Recommendation |
| TR1 (Benign) | <2% | No |
| TR2 (Not Suspicious) | <2% | No |
| TR3 (Mildly Suspicious) | ~5% | ≥2.5 cm: consider FNA |
| TR4 (Moderately Suspicious) | 5–20% | ≥1.5 cm: consider FNA |
| TR5 (Highly Suspicious) | >20% | ≥1 cm: consider FNA |
Fine Needle Aspiration (FNA) Biopsy
Used for nodules with intermediate to high TIRADS scores. Results are interpreted using the Bethesda System, which estimates cancer risk and determines next steps.
Bethesda Summary:
| Bethesda Category | Risk of Malignancy | Typical Recommendation |
| I – Non-diagnostic | ~5–10% | Repeat FNA |
| II – Benign | <3% | Follow-up |
| III – Atypia/FLUS | ~5–15% | Repeat FNA / molecular testing |
| IV – Follicular neoplasm | ~15–30% | Surgery often considered |
| V – Suspicious for malignancy | ~60–75% | Surgery |
| VI – Malignant | >97% | Surgery |
CT Scan of the Neck and Chest
Not needed in every case. Reserved for:
- Large or substernal goitres
- When ultrasound is inconclusive
CT provides a broader view of the thyroid’s size, location, and any compression of surrounding structures. It helps determine whether a chest (sternotomy) approach is necessary.
Thyroid Function Tests (TSH, T3, T4)
These indicate whether the thyroid is producing hormones appropriately.
If hormone levels are abnormal, they usually need to be stabilised before any planned surgery.
Surgical Decision-Making
Based on clinical assessment and investigation results, surgery may be advised. Options include:
- Hemithyroidectomy – removal of one thyroid lobe (used when the concern is limited to one side)
- Total thyroidectomy – removal of the entire gland (used in cancer, large multinodular goitre, or some hyperthyroid cases)
Risks of Thyroid Surgery
Thyroid surgery is generally safe but, as with all procedures, carries risks:
- Bleeding or infection
- Recurrent laryngeal nerve injury
May affect voice, cause aspiration, or (very rarely) require tracheostomy if both nerves are injured
- Parathyroid gland injury
May lead to low calcium levels, particularly after total thyroidectomy
- Hypothyroidism
Inevitable after total thyroidectomy—lifelong thyroid hormone replacement will be needed
- Neck dissection
Required if lymph nodes are involved in thyroid cancer
In Summary
Thyroid disorders vary widely in presentation and severity. Endocrine surgeons take a systematic, evidence-based approach to assess whether surgery is necessary—balancing risk, imaging findings, and hormone function. Collaboration with endocrinologists ensures the best possible outcome, whether the concern is a suspicious nodule, a large goitre, or uncontrolled hyperthyroidism.