In general, most thyroid nodules do not require surgery and should only be monitored regularly. Only a few malignant thyroid nodules require surgery. The thyroid gland is the endocrine organ responsible for metabolism in the body. It is located in the front of the neck on both sides of the trachea and resembles the left and right lobes of a butterfly. It is very common to find nodules in the thyroid gland in the population, but in the past, due to medical constraints, they were only detected when the neck became thicker. However, since ultrasound is commonly used for medical examinations, the detection rate of thyroid nodules has increased rapidly from 4% of the population to 19-67%. This means that 1 in 4 of us has a thyroid nodule, with women and the elderly being the majority. 80-90% of thyroid nodules are diagnosed as nodular goiter, which is a hyperplastic and degenerative disease of the thyroid tissue, not a tumor, and not an indication for surgery. Only about 5-10% are thyroid cancer, which requires surgery. In addition, there are about 10% of other benign nodular diseases, such as Hashimoto’s thyroiditis and thyroid adenoma, which usually do not require surgery. According to a statistic of thyroid surgery in Changchun, of the 9216 thyroid nodules treated with surgery, malignant tumors accounted for only about 10%, while benign nodules such as nodular goiter and adenoma accounted for about 90%. Since the detection rate of thyroid nodules can be as high as 19%-67%, it is not advisable or possible to operate on every patient with thyroid nodules in China with a population of 1.3 billion. However, due to the low level of ultrasound and cytology diagnosis in most hospitals in China, it is impossible to distinguish between benign and malignant nodules before surgery, so some doctors operate on all patients with thyroid nodules, which not only wastes a lot of medical resources, but also causes different degrees of damage to the patient’s appearance and function. We often encounter patients in our clinics who are confused by the different treatment opinions given by different doctors, such as surgery, observation, medication and puncture diagnosis, etc. The root cause is still due to the inconsistency in the level of knowledge of the doctors and the conditions in the hospitals. According to the standard procedure of thyroid nodule diagnosis in Europe and the United States and our practical experience, it is recommended that fine needle aspiration cytology be performed for nodules over 1 cm found by ultrasound. 1.Thyroid ultrasonography High-definition thyroid ultrasonography is the preferred and routine examination imaging test for evaluation and follow-up of thyroid nodules with the best efficacy ratio. By understanding the location, shape, size, number of nodules, nodule margin status, internal structure, echogenic features, blood flow status and cervical lymph nodes, most of them can initially identify the nature of nodules. At present, the accuracy of ultrasound diagnosis of benign lesions in our hospital is 86.0%, and the accuracy of malignant lesions is 82%. The diagnosis of benign nodules is based on: (1) multiple foci, (2) complete “halo” around the foci, (3) regular morphology of the foci, clear borders, uniform internal echogenicity, (4) coarse calcification images, (5) poor blood flow and predominantly peripheral blood flow, and (6) anterior-posterior diameter/transverse diameter ratio of 1. The diagnosis of malignant occupying lesions is based on: (1) single nodules, (2) irregular morphology of the foci, and (3) poor echogenicity of the nodules. (2) irregular morphology and poorly defined borders, (3) inhomogeneous internal hypoechogenicity, (4) fine sand-like calcifications, (5) abundant blood flow and predominantly internal blood flow, (6) anterior-posterior diameter/transverse diameter ratio of the nodule ≥1, and (7) metastatic enlargement of the cervical lymph nodes. High definition thyroid ultrasound can be used not only to determine the nature of thyroid nodules in general, but also to guide thyroid fine needle aspiration cytology. Fine needle aspiration cytology biopsy of thyroid nodules is the most accurate and cost-effective method for preoperative evaluation of the nature of thyroid nodules and is included as routine in all foreign guidelines. Approximately 300,000 new thyroid nodules are diagnosed each year in the United States, and about 96% are examined by puncture. However, in China, puncture is rarely performed due to outdated physician concepts, limitations in the level of cytopathological diagnosis, and excessive patient concern about thyroid nodules. Our hospital began performing thyroid FNA in October 2005 and has accumulated a wealth of experience. From October 2005 to January 2011, 474 cases of fine needle aspiration of the thyroid gland were performed at our hospital. The sensitivity of thyroid needle aspiration in identifying benign and malignant thyroid nodules is 85.4%, the specificity is 86.9%, and the positive predictive value is 90.5%, which is close to the international standard. According to the diagnostic strategy of thyroid fine needle aspiration of the Bartholin Society for Cytopathology, the diagnostic results are classified into six classes: malignant, suspected malignant, undiagnosed, atypical cells, follicular tumor and benign, which are used to guide the clinical treatment plan selection. 3. Treatment and follow-up of thyroid nodules 3.1. Benign nodules For cases diagnosed as benign by thyroid puncture, the vast majority of scholars recommend clinical follow-up, and most patients can avoid surgery by means of regular review. A large sample of data confirms that patients with benign punctures have only a 0.6-3% chance of developing thyroid cancer during long-term follow-up, and most of them can be detected and treated promptly during subsequent follow-up. According to the results of our study, most of the very few missed thyroid cancers are microscopic and can be observed or surgery can be deferred. Diagnosis of benign nodules should be followed up with regular physical examination, TSH measurement and ultrasonography once a year for at least 3-5 years. Pharmacological treatment of benign thyroid nodules has no clear effect, and levothyroxine does not make benign nodules smaller, but may bring about side effects such as cardiac and skeletal problems. Therefore, it is no longer recommended for routine use. No definite efficacy of Chinese herbs and proprietary Chinese medicines has also been reported to be found. There is a concern that nodular goiter may become cancerous in the long term so surgery is an option. Although nodular goiter can be combined with thyroid cancer, to date there is no reliable evidence that nodular goiter can become malignant. It should be noted that not all benign thyroid nodules are absolutely not operated. A few patients with large thyroid nodules should be considered for surgery in the following cases: 1) compression of the trachea affecting breathing, 2) affecting the appearance of the neck, 3) falling into the chest cavity developing into a retrosternal goiter, etc. 3.2, suspicious malignant and malignant For thyroid puncture cytology results of suspicious malignant and malignant cases should be operated according to the results of our study, 97.6% of patients with puncture malignancy were pathologically confirmed as malignant thyroid tumor after surgery, and 83.3% of puncture suspicious malignancy were confirmed as malignant tumor. Once the malignancy was confirmed, it was treated according to the principles of thyroid cancer, and the specific surgical plan will be described in a separate article. Postoperative follow-up will also be performed according to the principles of thyroid cancer follow-up. 3.3. Safety Whether thyroid puncture will lead to tumor implantation is always a major concern for patients. Since the majority of thyroid cancers are papillary carcinomas, which can generally be diagnosed based on cell morphology, fine needle puncture is recommended and coarse histological puncture is not recommended, which can significantly reduce the risk of implantation. In the literature, it is reported that about 300,000 patients undergo thyroid FNA each year in the United States, and as of January 2010, the cumulative number of reported cases of thyroid puncture resulting in tumor implantation was only 19, which shows that the chance of fine needle puncture resulting in implantation is minimal and safe. However, we must point out that the national situation of China is that the level of different regions and hospitals varies greatly, and different treatment guidelines can only be adopted according to the actual level of medical treatment in different regions and hospitals. Some large hospitals in Beijing, Shanghai and Guangzhou that are in a position to do so can try to align with the international advanced assessment methods and judge the need for surgical treatment mainly based on the puncture cytology results, avoiding the waste and damage caused by excessive treatment. Provincial and municipal hospitals can rely mainly on the ultrasonographic features provided by ultrasonography for surgical selection, such as the presence of microcalcifications in nodules, hypoechoic solid nodules or abundant blood flow in nodules, suggesting the possibility of malignancy can be operated directly, and then intraoperative judgment of benign and malignant based on frozen sections. If ultrasound diagnosis in the primary unit does not provide useful information, direct surgery can be considered when the patient has the following medical history and examination: (1) history of radiation exposure to the head and neck, (2) family history of thyroid cancer, (3) fast-growing thyroid nodules, (4) hoarseness, (5) enlarged ipsilateral cervical lymph nodes, etc., (6) single solid nodule in men, (7) age ≥45 or <15, (8) mass diameter >4 cm, (9) hard nodules, (10) adhesions with The nodules are hard, ⑩ adherent to the periphery, poorly mobile, etc. In summary, the majority of thyroid nodules are benign and do not require surgery. Only 5-10% of malignant tumors require surgery. The key to distinguish benign from malignant thyroid nodules is fine needle aspiration cytology diagnosis. In addition, most thyroid cancers are differentiated thyroid cancers that develop slowly and have excellent outcomes, so there is no need for excessive surgical treatment of all thyroid nodules. The purpose of protecting people’s health and saving a lot of medical resources is achieved.