With the improvement of people’s living standard and health awareness, the function and status of the thyroid gland and other endocrine organs are getting more and more attention, and in some large medical check-up centers, functional tests and ultrasound examinations of the thyroid gland are included in the routine examination items, and abnormalities of thyroid function and morphology are increasingly detected. ]. The vague diagnostic findings make many people nervous about the possibility of having thyroid tumors or even thyroid cancer. In addition, in primary care hospitals, most patients diagnosed with thyroid nodules are seen in general surgery, while a few are seen in the two gland departments (or thyroid and breast surgery) and head and neck surgery, and there are various principles for the management of thyroid nodules. The non-specialization of surgery and the lack of formal training in anatomy and operation lead to complications in thyroid surgery. Unilateral injury to the recurrent laryngeal nerve and superior laryngeal nerve is a common complication, and bilateral injury to the recurrent laryngeal nerve, hypoparathyroidism, and permanent hypothyroidism also occur, affecting the patient’s quality of life and even the ability to work; they also cause a serious waste of our not abundant medical resources. The author randomly searched the literature of Wanfang Chinese database in 2013, using “thyroid”, “nodule” and “resection” as search terms, and retrieved 141 relevant papers. Among them, there were 13 papers with the purpose of treating thyroid nodules with more than 100 cases, and most of them reported only 10%-15% of the surgical cases with the purpose of treating thyroid nodules were malignant [2, 3], and only one reported 30% of malignancy [4]. There are even large tertiary care hospitals where the proportion of malignancy is only about 10% [5], even though in the other 90%, 20% of benign nodules require surgery, and still 70% of patients can be observed without surgical resection. It is generally accepted that the proportion of malignant thyroid nodules excised for surgery should be more than 70%, and the remaining 30% may be benign adenomas requiring surgery, or huge nodular goiters with symptoms of compression and surgery [6]. Therefore, thyroid nodules should be evaluated in detail, with the aim of making a more accurate diagnosis before surgery and targeted treatment to reduce unnecessary surgery. For benign nodules, even if patients have fear psychology or even cancer-phobia, after a clearer diagnosis and reasonable explanation, most patients are still willing to choose non-surgical treatment; after all, it is human instinct to tend to avoid harm. Diagnostic evaluation of thyroid nodules The evaluation of thyroid nodules is an important part of the diagnosis and treatment process of thyroid nodules, including clinical evaluation, ultrasound imaging, fine needle aspiration cytology, and serological evaluation. History taking is as important as clinical examination. For thyroid nodules, one should first focus on the assessment of clinical history, the time of nodule discovery, the speed of growth, etc. If a solid nodule grows faster recently, it may be a manifestation of malignancy; if it is a cystic solid nodule and suddenly increases in size with pain after a cold and cough, it may be an intracapsular hemorrhage; those with symptoms such as hoarseness and difficulty in breathing may be malignant tumor; the chance of malignancy of prepubertal thyroid nodules is 2 to 3 times higher than that of adults. Patients with history of radiation exposure, family history of thyroid cancer, especially medullary carcinoma, should be highly alert. Ultrasonography is the most convenient way to examine thyroid nodules. On 2D ultrasound images, ultrasound features such as solid nodules, aspect ratio ≥1, calcifications <2mm in diameter, irregular morphology, poorly defined borders, and type III blood flow are signs of malignant nodules. If all the above 6 features are present, the chance of malignancy should be above 90%. If 2 features are present, malignancy should be suspected and further puncture cytology or puncture histology with a sensitivity of 94% and specificity of 68% for diagnosis [7]. For thyroid nodules whose nature cannot be determined by ultrasound, ultrasound-guided thyroid nodule puncture should be chosen if the nodule is >1 cm in diameter. Ultrasound-guided thyroid nodule puncture is not too popularly carried out in China, and searching the Chinese internet for 3341 journal papers on thyroid during the 10 years from 2003 to 2013, only 33 were discussing the diagnosis of thyroid nodule puncture, and the proportion of the number of papers was only 1%, and it is known that puncture cytology is not too popular even in large tertiary care hospitals. In the US 2009 ATA and NCCN guidelines for the diagnosis and management of thyroid nodules, it is sought to obtain a preoperative cytologic or histologic diagnosis of thyroid nodules [8, 9]. CT can be used to assess the compression and invasion of the trachea by thyroid nodules, or to assess the relationship between lymph nodes and surrounding tissues when thyroid cancer has significantly enlarged lymph nodes in the upper mediastinum and cervical side, and is not used as a routine assessment of nodules 114 Chinese Otolaryngology Head and Neck Surgery / March 2014, Vol. 21, No. 3 segment; MRI and PET-CT are also not used as a routine assessment of nodules, because thyroid differentiation type tumors are generally slow-growing and do not always show up as obvious hypermetabolic lesions on PET-CT. Nuclear scan is also not used as a routine means of characterizing thyroid nodules. In patients with hyperthyroid nodules, nuclear scan may be chosen to identify whether the nodule is hyperfunctional or not, and if it is a hyperfunctional nodule, the chance of malignancy is small. Selection of indications for surgery for benign thyroid nodules Guidelines such as the ATA and NCCN [8, 9] both mention only the evaluation of benign thyroid nodules and do not advocate surgical treatment of benign nodules, nor do they even have any treatment recommendations. Domestic guidelines on the diagnosis and treatment of thyroid nodules and thyroid cancer also state that for benign thyroid nodules, only regular follow-up is generally required and no specific treatment is needed [10]. The key to the diagnosis and treatment of thyroid nodules is qualitative diagnosis, and for benign thyroid nodules, most of which do not affect the human body, Ge Minghua and Wang Jiafeng [11] argued that unnecessary surgery violates ethical principles. If the surgery is performed because of financial gain it needs to be condemned more severely. Especially in patients with nodular goiter, there are varying degrees of overtreatment with partial thyroidectomy or even total thyroidectomy [12, 13], and even with endoscopic surgery, there is no guarantee that no trauma or complications will occur. The guidelines published in 2012 on the diagnosis and treatment of thyroid nodules and differentiated thyroid cancer in China also take into account the national situation and suggest that some benign nodules can be treated surgically, but there should be indications for selection; the guidelines stipulate the following indications for surgical treatment of benign thyroid nodules: ① the presence of local pressure symptoms associated with the nodules; ② the combination of (ii) Combined hyperthyroidism, where medical treatment is ineffective; (iii) A mass located in the posterior sternum or mediastinum; (iv) Progressive growth of the nodule with clinical consideration of malignant tendency or high risk factors for combined thyroid cancer [10]. Thyroid surgeons should follow these surgical indications. The guidelines also point out that a strong request for surgery due to excessive appearance or ideological concerns affecting normal life can only be a relative indication for surgery. In practice, after adequate discussion with patients and explanation of the pros and cons, the vast majority of patients with thyroid nodules do not actively choose surgical treatment. Selection of the scope of surgery for benign thyroid lesions The scope of surgical excision for benign thyroid nodules should be appropriate to avoid an excessive scope. The design of the surgical plan should be based on the size and number of the tumor and the state of thyroid function of the patient, and also consider the surgical technique of the surgeon, the degree of knowledge of the disease, and the condition of the medical equipment; if there is no clear qualitative diagnosis before surgery, there should be a rapid intraoperative frozen disease examination before deciding the scope of surgery, and we firmly oppose blind surgery without either qualitative diagnosis before surgery or qualitative diagnostic measures during surgery, and if If there is no intraoperative rapid freezing condition, it is recommended that thyroid surgery should not be performed. This is because an inappropriate surgical scope leads to a significant increase in the chance of secondary surgery and a significantly higher incidence of complications of the recurrent laryngeal nerve and parathyroid glands [14, 15]. For single nodules confined to one side, either a lobectomy or a subtotal resection with preservation of the posterior tegument can be performed; whereas for unilateral multiple nodules, a total resection of one glandular lobe is usually required, and if the technique of revealing the recurrent laryngeal nerve and parathyroid glands is unskilled, the external and posterior tegument of the thyroid gland can be preserved after revealing the nerve. In the case of bilateral multiple benign thyroid nodules, it is important to protect the function of the parathyroid glands during surgery. If the parathyroid glands can be correctly identified during surgery, a subtotal resection with one glandular lobe removed and the posterior part preserved on one side can be done [16], and if the parathyroid glands cannot be correctly identified, it is better to do a bilateral subtotal or near-total resection. Each nodule should be carefully examined during surgery with frozen pathology to prevent missing thyroid cancer, often large nodules are benign and small nodules are malignant, and if malignant lesions are present, surgery is performed according to the principles of thyroid cancer management [10]. The use of total thyroidectomy for benign thyroid disease can reduce the incidence of reoperation and seems to be a once-and-for-all approach, but postoperative levothyroxine is required to replace thyroid function, and lifelong medication causes inconvenience to patients. Some scholars believe that total thyroidectomy is not the direction of surgical development for benign thyroid lesions [17]. However, looking at the domestic literature in recent years, there are still a large number of cases reporting total thyroidectomy for nodular goiter [12, 13]. In conclusion, surgical treatment of thyroid nodules should be approached with caution, with a good assessment of benignity and malignancy first, and for benign nodules, especially nodular goiter, unless there are symptoms of compression or retrosternal goiter, non-surgical treatment should generally be chosen.