Thyroid nodules: euthyroid, thyroid dysfunction and suspected cancer (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • All NHS Highland 
  • Primary and Secondary Care 
  • Adults and Children 

Thyroid cancer

Refer a person with a thyroid nodule, and one or more of the following features to the ENT Neck Lump Service as a USC (urgent suspected cancer):

  • Nodule rapidly increasing in size
  • Associated unexplained hoarseness
  • Associated cervical lymphadenopathy
  • Previous neck irradiation
  • Family history of endocrine tumours
  • Person aged 16 years or under

See: Scottish referral guidelines for suspected cancer: Head and neck and thyroid cancers | Right Decisions for more details.

The Scottish Referral Guidelines for Suspected Cancer support primary care clinicians in identifying patients who are most likely to have cancer and therefore require urgent assessment by a specialist. Equally, the Guidelines help in identifying patients who are unlikely to have cancer, embedding safety netting as a diagnostic support tool.

Pathway

 

Thyroid nodule found clinically or incidentally on imaging
Check thyroid function
(Ultrasound of thyroid will be organised at outpatient clinic if clinically indicated)
Hypothyroid
 (Low fT4, Raised TSH)
Euthyroid
(including all PET avid nodules or suspected cancer)
Hyperthyroid Suppressed TSH +/- elevated fT4
Initiate levothyroxine, if appropriate and arrange follow-up in Primary Care
Refer to ENT Neck Lump Clinic
Consider initiation of antithyroid therapy if symptomatic or overt hyperthyroid TFTs
Refer to ENT Neck Lump Clinic
Refer to endocrinology for further evaluation

Treatment

See Highland Formulary: Antithyroid drugs

Carbimazole tablets 5mg, 20mg

Dose: The initial dose can range from 5 to 40mg daily depending on the degree of hyperthyroidism, with repeat thyroid function usually after 4 weeks. The dose may then be progressively reduced to the lowest dose to maintain thyroid function within range. If unclear which dose to initiate, endocrinology can advise on receipt of referral, or seperately via Clinical Dialogue. Please note that propylthiouracil is the antithyroid drug of choice in the first trimester of pregnancy.

Levothyroxine

Levothyroxine (T4) should be initiated once daily at a dose of 0.8 to 1.6 micrograms/kg, which is usually 50 to 125 micrograms. A lower dose should be used for elderly patients and patients with cardiac disease. It must be taken on an empty stomach, with no food consumption for 30 minutes. Not taking it in this way may prevent optimised treatment.

The aims of treatment are to manage the patient's hypothyroid symptoms and maintain thyroid stimulating hormone (TSH) levels within the normal range. If the TSH levels are too low then there is an increased risk of developing atrial fibrillation and osteoporosis. If the aims of treatment are not achieved with levothyroxine then the following should be checked:

  • Is the dose correct for the weight of the patient?
  • Is the treatment being taken correctly on an empty stomach?
  • Are there other treatments that might impair absorption (antacids, proton pump inhibitors, histamine-2-receptor antagonists)?
  • Are there other undiagnosed endocrine or auto-immune conditions?
  • Are there other causes of fatigue (depression, fibromyalgia, etc)?

These factors should be taken into account for any patient being considered for liothyronine (T3) treatment and when reviewing existing patients. Liothyronine must ONLY be initiated by an endocrinologist. 

Further information

Further information is available from the British Thyroid Association: Management of Primary Hypothyroidism & FAQs for GPs

Abbreviations

ENT:  Ear, Nose and Throat
fT4: Free Thyroxine
kg: Kilogram
mg: Milligram
PET: Positron Emission Tomography
T3: Triiodothyronine
T4: Thyroxine
TSH: Thyroid Stimulating Hormone
USC: Urgent Suspected Cancer

 

Editorial Information

Last reviewed: 24/03/2026

Next review date: 24/03/2029

Author(s): Endocrinology, ENT.

Version: 3

Approved By: pending approval TAM subgroup of the ADTC

Reviewer name(s): A Isa, ENT Consultant and D MacFarlane, Consultant Physician.

Document Id: TAM184