When should I consider referring a patient with a thyroid nodule for specialist assessment?

Consider urgent specialist referral (within 2 weeks) to a thyroid surgeon or endocrinologist if the patient has:

• An unexplained thyroid lump.
• A thyroid mass associated with unexplained hoarseness or voice change.
• A thyroid mass with cervical or supraclavicular lymphadenopathy.
• A sudden onset of a rapidly expanding painless thyroid mass significantly increasing in size over days or weeks.
• A suspected thyroid nodule with other red flags or risk factors for malignancy.
• A thyroid nodule causing compressive symptoms such as breathlessness or dysphagia.

For children with a thyroid nodule or goitre, arrange urgent referral to a paediatric endocrinologist or general paediatrician depending on local services.

For other patients with a suspected thyroid nodule:

• Arrange serum thyroid function tests (TFTs) in primary care first.
• Refer routinely to endocrinology if there is a non-suspicious thyroid nodule with abnormal TFTs or with normal TFTs.
• Refer urgently if there is sudden-onset painful expansion of a thyroid lump (likely haemorrhage into a benign cyst).
• Refer if an incidental thyroid nodule >1 cm is found on imaging without suspicious features.

Consider monitoring in primary care without referral if:

• There is a longstanding, stable thyroid nodule with no lymphadenopathy or red flags.
• There is a non-palpable, asymptomatic incidental thyroid nodule <1 cm without lymphadenopathy or red flags.

Do not routinely arrange neck ultrasound in primary care as this may delay diagnosis; ultrasound and further investigations are best arranged after specialist referral.

These recommendations are based on NICE, British Thyroid Association, and other expert guidelines aiming to exclude thyroid cancer and identify patients needing specialist assessment promptly ¹,²,³.