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Background: Clinically relevant thyroid carcinomas can be found in 5-6% of nodular goiters which undergo surgery. Moreover, multinodular goiters fre- quently contain hot areas. Therefore, efficient and rational methods for the differential diagnosis and decision are required to identify those nodules with an increased cancer risk or those which are hot among the many thyroid nodules., Methods: Description of a newly revised and further guidelines and consensus statements as well as selected literature search., Results: Already history, ultrasound and TSH (thyroid-stimulating hormone) determination do allow a first risk assessment for the further diagnostic work-up. Fine-needle biopsy (FNB) offers the best sensitivity and specificity for the distinction between benign and malignant thyroid nodules. The combination of several clinical and ultrasound criteria and laboratory determinations (calcitonin) can help with the selection of thyroid nodules with scintigraphically normal or decreased uptake > 1 cm for FNB. However, the efficiency of FNB requires sufficient training and experience of both the cytopathologist and the person performing FNB., Conclusion: Whereas solitary thyroid nodules with a suspicion for malignancy should be referred to the surgeon, euthyroid thyroid nodules without clinical ultrasound or cytological indicators of malignancy may be followed up - possibly under medication -, if surgery is not indicated by local complaints, tracheal or mediastinal involvement.

Graves' disease and toxic uni- or multinodular goiter are the most frequent causes of hyperthyroidism. Graves' disease is caused by thyroid stimulating immunoglobulins which are directed against the TSH receptor of thyroid follicular cells. Graves' disease affects more females than males and is associated with diffuse goiter and a rapid appearance of symptoms and signs of hyperthyroidism. Patients with Graves' disease are on average younger than patients with toxic nodular goiter. The diagnosis of Graves' disease is usually easy, particularly if signs of endocrine opthalmopathy are present. Toxic nodular goiter is seen more often in older patients with pre-existing goiters. Symptoms and signs of hyperthyroidism often appear only slowly. Hyperthyroidism in these older patients can be oligosymptomatic. Older patients should therefore be investigated for the presence of hyperthyroidism, even if they present only a few symptoms or signs which could suggest this diagnosis. The development of ultrasensitive TSH assays has simplified the diagnosis of hyperthyroidism and made the TRH-test, often used in the past, almost superfluous. At the present time, it is practically always possible to differentiate between Graves' disease and toxic nodular goiter as the cause of hyperthyroidism on the basis of clinical and laboratory findings alone, and in many cases thyroid scintiscans are therefore no longer necessary. A patient with newly diagnosed Graves' disease is treated with antithyroid drugs (carbimazole or PTU) for one year. If hyperthyroidism persists after this one year of antithyroid drug treatment, or if it recurs, another year of therapy with carbimazole or PTU is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

A method for electrophysiological monitoring of the recurrent laryngeal nerve during thyroid surgery is described. An electromyographic record from the muscles of the vocal folds is obtained using two fine needle electrodes. The electrodes are placed endoscopically. The nerve is identified by electrical stimulation, and the electromyographic activity is registered using a Nerve Integrity Monitor NIM-2 (Xomed-Treace). Our experience with this method in 43 patients is described. The safety of the integrity of the recurrent laryngeal nerve is increased using intraoperative monitoring. This has led to a modification of the operative concept in thyroid surgery. Electrophysiological monitoring is mandatory in surgery of large goitres, retrotracheal and substernal extension, for re-operations and malignant diseases of the thyroid gland.