History

Unfortunately, the history is neither sensitive nor specific in detecting underlying malignancy. However, the development of hoarseness, progressive dysphagia, or shortness of breath suggests growth or invasiveness, and it should raise the index of suspicion of malignancy. Prior irradiation for such conditions as thymic or tonsillar enlargement, or acne, as well as a family history of thyroid cancer predisposes to cancer. Male sex, in general, and nodules that appear in individuals younger than 20 years or older than 60 years, in particular, are additional risk factors for malignancy. The following elements of the history would suggest a benign process: a sudden or gradual onset of pain or tenderness (that would suggest either hemorrhage into a benign adenoma or cyst, or subacute granulomatous thyroiditis, respectively); symptoms of hypothyroidism (suggesting chronic autoimmune [Hashimoto] thyroiditis); and a family history of benign thyroid nodular disease, Hashimoto thyroiditis, or other autoimmune disease. However, thyroid cancer may occasionally be painful or tender.