What are the current guidelines for the management of benign thyroid nodules in primary care?

In primary care, the management of benign thyroid nodules involves several key steps. Initially, arrange serum thyroid function tests (TFTs) to assess thyroid status, as this helps guide further management and referral decisions ¹. Routine neck or thyroid ultrasound is not recommended in primary care because it may delay diagnosis; however, ultrasound should be considered if malignancy is suspected or if clinical factors suggest it ¹,².

For adults with non-malignant thyroid enlargement and normal thyroid function who have mild or no symptoms, no treatment is offered unless there is breathing difficulty or marked airway narrowing ². Monitoring in primary care is appropriate for longstanding, stable nodules without red flags or risk factors for malignancy, and for small (<1 cm), asymptomatic incidental nodules without lymphadenopathy ¹. Repeat thyroid ultrasound and TSH measurement should be considered if malignancy or compression is suspected, or if symptoms worsen or new symptoms such as hoarseness or shortness of breath develop ².

For cystic nodules causing compressive symptoms, aspiration is offered, with possible ethanol ablation if fluid re-accumulates ². For non-cystic nodules or multinodular goitre with compressive symptoms, consider referral for surgery, radioactive iodine ablation, or percutaneous thermal ablation ². Urgent referral to specialists is indicated if there are red flags such as unexplained thyroid lumps, associated hoarseness, lymphadenopathy, rapid growth, or compressive symptoms ¹.