Diagnosis and Surgical Management of Solitary Thyroid Nodule

Preoperative distinction between benign and malignant in solitary thyroid nodules is important. It helps to avoid unnecessary surgery and its adverse effects, such as hypothyroidism, hypocalcemia, and recurrent nerve injury. Methods Descriptive perspective analyzed data over a period of 6 years April 2015__April 2021 in Saudi Hospital at Hajjah, Yemen. 226 thyroid operations for 207 patients ,135 patients diagnosis as Solitary thyroid nodule and 72 patients as Multi nodular goiter. Patients with a clinically solitary thyroid nodule were included in the study group. Results


Introduction
Solitary thyroid nodules are de ned clinically as localized thyroid enlargement with an apparently normal remaining gland and refer to abnormal growth of thyroid cells that forms a lump within the thyroid gland. Although the vast majority of thyroid nodules are benign, a small proportion of thyroid nodules contain thyroid cancer. To diagnose and treat thyroid cancer at the earliest stage, most thyroid nodules need signi cance) and category IV (suspicious for follicular neoplasm) according to the Bethesda system [15,16].
Fine-needle aspiration cytology (FNA) is regarded as the rst diagnostic step to differentiate malignant from benign nodules. FNA has served with high accuracy to diagnose papillary thyroid carcinoma, which accounts for 80%-90% of all thyroid cancers because papillary thyroid carcinoma has several speci c cytological nuclear features, such as optically clear elongated nuclei with nuclear grooves and intranuclear cytoplasmic pseudoinclusions [17,18,19] Fine-needle aspiration cytology (FNAC) has become the cornerstone investigation. Unfortunately, on the basis of cytological characteristics alone, pathologists cannot reliably distinguish benign from malignant follicular thyroid lesions, ∼20% of ne-needle aspiration cytology (FNAC) will be given a nal diagnosis of follicular malignancy. [20].
For benign solitary nodules, hemithyroidectomy of the involved lobe is recommended, not total thyroidectomy, but in treating suspicious and false-negative (FN) cases, ne-needle aspiration cytology (FNAC) reports could be overcome by total thyroidectomy. Hemithyroidectomy with or without isthmusectomy is performed as the initial operation for patients with an indeterminate cytological diagnosis and no clinical evidence of regional or distant metastatic disease or any other concurrent indication for total thyroidectomy. If gross extrathyroidal tumor extension or lymph node metastasis is found at the time of operation, a total thyroidectomy is then carried out [21].
The aim of the present study was to evaluate patients with clinically detected solitary thyroid nodules for the presence of malignancy in relation to various factors, such as age, gender family history, rapid growth and hard clinical examination, xed nodules and ultrasonography (USG) ndings, such as the size of the nodule, echogenicity, microcalci cation, and presence of lymphadenopathy, as well as ne-needle aspiration cytology (FNAC) results. We also planned to compare the prevalence of malignancy in both solitary and multiple thyroid nodules detected by ultrasonography (USG).

Materials And Methods
This is a descriptive perspective analyzed our departmental data over a period of 6 years April 2015__April 2021. In Saudi hospital at Hajjah,Yemen. Approximately 226 thyroid operations were performed for 207 patients; 135 patients were diagnosed with solitary thyroid nodules, and 72 patients were diagnosed with multinodular goiters. All patients who underwent surgery in the surgical department with a clinically detected solitary thyroid nodule were included in the study group. Our approach was individualized as single team. Preoperative history, examination, thyroid function test, ultrasonography (USG) and ne-needle aspiration cytology were planned in all these patients. Hemithyroidectomy and total thyroidectomy with and without neck dissection were performed wherever appropriate. The patients and their relatives gave consent to use the information for publication purposes. The study was approved by the institutional ethics committee.
For all patients, the following data were recorded: age, sex, history of radiation exposure, family history of thyroid disease, symptoms and growth rate of nodules, and thyroid hormone pro le. The operative procedure was based on different parameters, such as the age of the patients, clinical examination, ultrasound interpretation, ne-needle aspiration cytology (FNAC) ndings and indirect laryngoscopy. The decision for surgery was based on individual patient examination and investigation ndings.
In most of the patients, the plan of surgery was decided beforehand. If it was a solitary thyroid nodule diagnosed clinically , ultrasonographically and ne-needle aspiration cytology (FNAC) as malignancy or high suspicion for malignancy proceeded with total thyroidectomy. For others, lower grade hemithyroidectomy of the involved side was performed, and the specimen was sent for routine histopathological examination (HPE). Because of inconclusive results and the lack of frozen section use, we preferred to wait until the nal histopathology report. If the histopathological result was positive for malignancy, completion thyroidectomy was performed in 4_6 weeks. The decision for other procedures, total thyroidectomy with central neck dissection, total thyroidectomy with selective neck dissection, and total thyroidectomy with modi ed radical neck dissection, was based on clinical, radiological, ne-needle aspiration cytology (FNAC) and histopathology ndings.
During surgery, the site and type of incision were decided. Hemostasis, safeguarding of the recurrent laryngeal nerve, parathyroid, and other vital structures, was taken care of during the dissection.
Appropriate measures were taken to correct postoperative hypocalcemia, and care of the drain was taken. Further treatment plans were decided based on the nal histopathology report. If the report was benign, the patient was managed by regular monitoring of hormone levels, with or without thyroid hormone supplementation. Hypocalcemia features were managed with supplementation with calcium and vitamin D.
If the nal histopathology report was either follicular or papillary carcinoma, the patients were advised to undergo an I-131 whole body scan, preferably within 4-6 weeks after surgery, and radioactive iodine ablation was advised for residual tissue in the thyroid bed. All the patients were advised regular followup for one week, one month, 6 months, one year, and 2 years. Before the operation history and clinical examination were performed for all patients, the most common presentation of STN was swelling in the anterior aspect of the neck. Swelling was noticed by the patient's relatives in most instances and, in a few cases, by the patients themselves. Other less common symptoms were pain, hoarseness and dysphagia. The duration of symptoms ranged from one to 24 months. Rapid growth of nodules lasted signi cantly last 3_6 months in 20 cases, family history of thyroid nodules was positive in 10 cases, and hard nodules were positive in 32 cases.
Laboratory tests, including thyroid function tests, showed (Table 5) thyroid function tests were performed in all 135 patients. A total of 125 (93%) patients were euthyroid, 6 (4%) were hypothyroid, and 4 (3%) were hyperthyroid. Before surgery, these patients were euthyroid by supplementing thyroxin or by treatment with antithyroid drugs.
Hypothyroidism occurred in 5 females and one male, hypothyroidism occurred in 4 patients with Rt solitary thyroid nodules, and 2 patients had Lt solitary thyroid nodules.
by FNAC 2 cases with Benign colloid nodule with compression symptoms, one case follicular neoplasia ,one case Hurthle cell neoplasia , one case suspicious categories, one case papillary thyroid cancer . Benign solitary thyroid nodules appeared in 3/6 (50%) patients, with hypothyroidism. All patients were female, 2 on the Lt side and one on the Rt side. The results of histopathology were Hashimotos thyroiditis in 2 cases and one case of colloid goiter with a hyperplastic nodule. After becoming euthyroid by medical treatment, surgery was performed by total thyroidectomy in 2 cases and Rt hemithyroidectomy in one case.
Malignant solitary thyroid nodules appeared in 3/6 (50%) patients with hypothyroidism before the operation. The histopathology results showed malignant nodules such as papillary thyroid cancer on a background of Hashimotos thyroiditis, one of whom had lymph node metastasis. This means a higher risk for malignant transformation, especially papillary thyroid cancer , than lymphoma after becoming euthyroid by hormonal replacement and undergoing thyroid surgery.
Total thyroidectomy with central lymph node dissection in one patient and total thyroidectomy with Rt lymph node dissection in one patient were complicated by temporary horsnese due to laryngeal edema that improved during the rst month.
Rt hemithyroidectomy followed by completion Lt hemithyroidectomy with central lymph node dissection was performed in one patient. It should be noted that all patients received postoperative thyroid hormone replacement, and it should also be noted that not all cases of hypothyroidism were hashimatous thyroiditis, as one case of hypothyroidism and histopathology result was colloid goiter with a hyperplastic nodule.
Hyperthyroidism appeared in 4/100 patients. All females had benign solitary thyroid nodules on the Rt side. Histopathology results were benign toxic adenomas in 3 cases and colloid goiter hyperplastic nodules in one case. After becoming euthyroid by medical treatment, the patient underwent surgery by total thyroidectomy, subtotal thyroidectomy, near total thyroidectomy and one case of Rt hemithyroidectomy. Post-hemithyroidectomy was euthyroid follow-up for 5 years, with no recurrence until now, and no patients received any replacement, but all other 3 patients received thyroid hormone therapy.
Ultrasound examination ndings (Table 6) were available in 135 clinically detected solitary thyroid nodules. Clinical diagnosis of solitary thyroid nodules was con rmed on ultrasound in 85 (63%) patients, whereas in 32 (24%) patients, ultrasound revealed a prominent nodule of multinodular goiter.
Postoperative histopathology was available for 135 patients, and 35 nodules were reported as malignant. Twenty-three (66%) true solitary thyroid nodules turned malignant on postoperative histopathology, while 12 patients (34%) had prominent nodules of multinodular goiter.
The majority of the nodules (n=67, 50%) were 2-4 cm in size. However, there was no signi cant correlation between tumor size and the risk of malignancy.
In addition, ultrasound detected microcalci cations in 38 patients, of whom 28 were malignant and 10 nodules with microcalci cations were benign. Thus, 28 out of a total 35 (80%) malignant cases had microcalci cations, in contrast to 10 of 100 (10%) benign nodules. Lymph nodal enlargement was detected by ultrasound in 26 patients. Twenty-four of 35 (69%) malignant nodules had lymph node enlargement compared with only 2 of 100 (2%) benign nodules .
Twelve patients had benign hyperplastic nodular goiter, 2 of whom had cystic changes and marked brosis and calci cation. And one them with hyperplastic papillary nodule in benign nodular goiter, 5 patients with benign cystic nodule 3 of them with hemorrhagic cystic nodule and 2cases colloid cystic nodule, 7 patients with chronic thyroiditis (hashimotos and lymphocytes thyroiditis ),3 cases with hypothyroidism,3 patients with toxic adenoma and hyperthyroidism with average nodule size 4-5cm,28 patients with benign follicular adenoma 3 of them with lymphocytic thyroiditis and one case with cystic degenerative changes, 6 patients with benign hurthle cell adenoma (oncocystic neoplasm) and 6 patients with Non invasive follicular thyroid neoplasia with papillary nuclear like features (NIFTP) ,This type of thyroid tumor was previously classi ed non invasive encapsulated follicular variant of papillary thyroid cancer , but before few years reclassi ed this tumor as non malignant because character by absent capsular, vascular invasion ,tumor necrosis, high mitotic activity and have indolent behavior and may be over treatment if classify as type of cancer , All 6 patients was female ,between age 22_58 years ,mean 40.83 years ,median age 41 year, with standard deviation 12.38.
Four patients were diagnosed with Lt Solitary thyroid nodules, and 2 patients were diagnosed with Rt Solitary thyroid nodules. The average size was 2_4 cm in 3 patients, 1_2 cm in 1 patient and 4_5 cm in 2 patients. Fine needle aspiration cytology showed benign cytology in 3 patients, follicular neoplasia in 2 patients and suspicious nodules in 1 patientAll 6 patients were euthyroid before the operation, 3patients underwent Lt hemithyroidectomy, and 2 patients underwent Rt hemithyroidectomy.
Considering this term benign and not followed by total thyroidectomy, only follow-up is needed.
One patient underwent total thyroidectomy because it was in the suspicious category. One patient developed postoperative temporary horses that improved after a few weeks.

Management
Depending on the interpretation of the FNAB cytological specimen, management consists of observation, levothyroxine suppression therapy, or surgery.
Patients with benign solitary thyroid nodules may undergo observation or levothyroxine suppression therapy as the initial treatment modality. Levothyroxine is typically administered for 6-12 months to determine if the solitary thyroid nodule decreases in size. If the nodule decreases in size after treatment with levothyroxine, this medication is discontinued, with follow-up examination of the thyroid nodule in 3-6 months. However, if a benign solitary thyroid nodule increases in size, a repeat trial of levothyroxine and repeat FNAB may be indicated. Additionally, growth of a thyroid nodule during levothyroxine therapy is a strong indication for surgery.
No consensus exists regarding the degree of thyroid suppression or the e cacy of levothyroxine therapy. In fact, many endocrinologists no longer recommend thyroid suppression because of potential long-term adverse effects, such as osteoporosis and cardiac arrhythmias. Still others maintain a thyroid-stimulating hormone (TSH) level ranging from 0.1-0.3 mU/L rather than suppressing to the lowest limits of detectability to avoid immediate toxicity and long-term side effects.
Solitary thyroid nodules that are malignant, suspicious, or indeterminate on FNAB require excisional biopsy in the form of thyroidectomy. Considerable controversy exists regarding the extent of surgery for malignant, suspicious, or indeterminate solitary thyroid nodules.

Type of Surgery and operative ndings
Patients with solitary thyroid nodules who underwent surgical procedures In

Complications
In Table 17, complications after thyroidectomy for solitary thyroid nodules appear. Three patients after total thyroidectomy with Hashimotos thyroiditis and lymphocytic thyroiditis One case post total thyroidectomy with follicular adenoma ,3 cases post Total thyroidectomy with central lymph nodes dissection with papillary thyroid cancer in ltrated ,One case post Total thyroidectomy with Selective Rt lymph nodes dissection with papillary thyroid cancer with lymph node metastasis and One case post Total thyroidectomy with modi ed Rt and Lt neck dissection.
All females were aged 20-62 years. All nodules were hardly xed, with an average nodule size of 2_5 cm. One case after total thyroidectomy for anaplastic thyroid cancer older age in ltrated tumor big tumor size 6_9 cm and 1 case after total with selective Rt Neck dissection for patients with papillary thyroid cancer with lymph node metastasis and 1 case post Lt hemithyroidectomy for patient with Noninvasive follicular neoplasia with papillary like features was 29 years old female developed temporary horsnese was improved after few weeks. All patients appeared horsnese directly after the operation; they received a warm slin nebulizer and dexamethasone for 24_48 hours, and the hospital stay was not completely improved by 3_6 months.
The postoperative hospital stay ranged from one to 3 days, and the mean hospital stay was 2 days.
Follow-up ranged from one to 48 months with a mean follow-up of 12.1 ± 14.2 months.

Discussion
Thyroid nodules refer to localized lesions within the thyroid gland that are palpably or radiologically distinct from the surrounding thyroid parenchyma. [22].
Because of the high risk for malignancy , surgeons tend to treat them with a high degree of suspicion and plan treatment in a systematic manner. Clinically, STNs are common and are present in up to 50% of the elderly population. The majority of STNs are malignant. [ 2, 10 , 11] . Thyroid nodules are more common in females similar as noted in the previous study. [ 2,6].
Solitary thyroid nodules were 10-11times more common in females as compared to males, [ 2,10], Our study showed that solitary thyroid nodules were 14 times more common in female than male.
In our study 135 Patients with Solitary Thyroid Nodule b/n age 14-65 years, median age 41 years, mode 45 years , average mean age 39.76 years, range 51 years and Stander deviation 13.98 . The age range and mean slightly wide, and higher compared with previous study by (Gupta ). [ 10].
In our study Solitary thyroid nodule more Common in age group between 21-30 years old are about 50 patients and the next age group between 41-50 years old are about 29 patients. That mean second decade involved by majority of the patients (37%) this is lower than previous study by Gupta [[10] and Dorairajan and Jayashree in that third decade of life majority of the patients involved (44%). Further investigation should be considered if the following factors are present in addition to the thyroid nodule like male gender, extremes of age (<20 or >70 years), history of neck irradiation, nodule >4 cm in size or the presence of any pressure symptoms.
[ 22] None of our patients in the study group had history of radiation exposure.
Patients under the age of 20 or over 70 years with thyroid nodules have an increased risk of malignancy, as do men. A history of persistent hoarseness, dysphagia, or dyspnea also increases the risk, although these symptoms may also occur with benign nodules. Rapid painless growth of a solid nodule is concerning and raises the suspicion for thyroid cancer. [25].
Numerous studies have documented that the risk of malignancy in patients with thyroid nodules is 5%-17%, whether detected by palpation or ultrasonography.
There were 135 cases of clinically detected STNs with available ultrasound ndings in the study group.
Thirty-ve (26%) (3:1) clinically detected STNs were reported as malignant in the nal HPE. This high incidence of malignancy reported in our study is similar to that of Tai et al. [ 2]. A total of 36.6% (97) of the 265 patients also reported a 20% and 42.27% incidence in the papers. [ 10,11] were proven to be malignant, which was higher than the general incidence of malignancy of 5%. It seems that STN has a higher risk of malignancy, so in this condition, we should focus on the potential danger to all these patients.
A retrospective study by Keh et al of 61 patients found that 75.4% of solitary thyroid nodules had a neoplastic pathology and 34.4% were malignant. [ 51] .
The rise in incidence seems to be attributable both to the growing use of diagnostic imaging and neneedle aspiration biopsy, which has led to enhanced detection and diagnosis of subclinical nodules [52] and early diagnosis of low-risk lesions [53].
The fact that the malignant percentages obtained in this study were higher is partly due to the pattern we used for selecting patients. In other words, we selected the cases from surgery wards, whereas other studies included in their experiments all the cases that were subjected to FNAC. As noted above, the risk of malignancy in this group has been reported to be 26%; however, a higher rate has also been reported. [ 38,39,40].
In our study, 35 patients were diagnosed with malignant solitary thyroid nodules; 31 patients were female, and 4 patients were male.
Additionally, malignancy was found in 4 (44%) out of 9 male patients with solitary thyroid nodules .
Hence, thyroid nodules predominate in females . [ 2,6] and the increased incidence of malignant thyroid nodules in males noted in our study are similar to those of Tai (55). Nevertheless, some studies, including ours, revealed that the prevalence of thyroid carcinoma is higher in younger patients [ 56,57].
In our study, most solitary thyroid nodules, even benign or malignant nodules, were between 2.1_4 Cm. The size of the nodule had no relation with malignancy in our study, which was also reported by Tai et al. [ 2] A study by Kamran et al. opined that the risk of follicular carcinomas and other rare thyroid malignancies increases as nodules enlarge. [ 27] However, no such association with size was seen in our cases.
Usually, the size of the thyroid nodule does not predict the likelihood of thyroid cancer. Only 8% of incidentally found thyroid nodules measuring <5 mm, 15% of nodules measuring 5-10 mm, and 13% of nodules measuring 10-15 mm are malignant [24].
The results of this study revealed that the size of thyroid nodules is not reliable at predicting malignancy and should not be applied in medical decision making. [58 ] [59] was similar to the our study .
A study by Valderrabano et al indicated that regardless of size, most solitary cytologically indeterminate thyroid nodules can be successfully treated with thyroid lobectomy. Comparing indeterminate tumors of less than 4 cm with those 4 cm or greater, size was not seen as a categorical or continuous variable in relation to cancer rate. Moreover, the prevalence of extrathyroidal extension, positive margins, lymphovascular invasion, lymph node metastasis, and distant metastasis did not differ by size. The investigators also found the majority of malignant tumors in both size groups to be low-risk lesions. [45].
In our study (72%, 63%), the Rt-side thyroid was more affected by either benign or malignant solitary thyroid nodules. A similar study by Liechty et al 9 noticed that there was a predilection for benign and malignant nodules to occur in the right lobe, and Robinson et al 1 also found that in 40% of cases, the nodules were located in the right lobe. [60].
Malignant solitary thyroid nodules appeared in 3/6 (50%) patients with hypothyroidism before the operation. The histopathology results showed malignant nodules such as papillary thyroid cancer on a background of Hashimotos thyroiditis, one of whom had lymph node metastasis. This means a higher risk for malignant transformation, especially papillary thyroid cancer, than lymphoma [ 50].
Ultrasonography is the most cost-effective imaging procedure and is highly sensitive in assessing nodule size and number. There are ultrasound patterns that suggest malignancy such as irregular shape, illde ned borders, hypoechogenicity, solid texture, heterogeneous internal echoes, microcalci cation, absence of a halo, an anteroposterior to transverse diameter ratio (A/T) >1, in ltration into regional structures, and suspicious regional lymph nodes. [ 22].
Thyroid ultrasonography can be helpful in certain cases when it is used to guide FNAB. Data have suggested that ultrasonography-guided FNAB may be preferable to palpation-guided FNAB. [61] Ultrasound may aid in the localization and examination of nodules, but FNA or excisional biopsy is necessary to de nitively determine the presence of malignancy [62].
addition, high-resolution ultrasound and ancillary testing in the form of molecular genetics and immunocytochemistry can improve diagnostic accuracy. [ 41][63].
The likelihood that the increased incidence of thyroid cancer is largely related to early detection by highresolution ultrasound and discovery of subclinical thyroid nodules.
[63 ] [64] is supported by evidence suggesting that survival rates for thyroid cancer have remained fairly stable. [65].
In our study, 28 patients out of a total 35 (80%) malignant cases had microcalci cations by thyroid ultrasound, in contrast to 10 of 100 (10%) benign nodules. This nding suggests that in the presence of microcalci cations, the incidence of malignancy is more similar to that in a study by Kuo et al, which indicated that on ultrasonographic examination, the presence of calci cations within a thyroid lesion and nodule-like solid masses are independent factors for thyroid cancer, especially follicular thyroid carcinoma instead of follicular adenoma. [47]. Additionally, an article by Rago et al. suggested that atypia at cytology and spot microcalci cation at ultrasound were predictive of malignancy [29].
The presence of solid echogenicity contributes to an increased incidence of malignancy in comparison to either cystic or mixed echogenicity of the nodule. [ 2] Our study showed that similar results were solid in 30/35 (86%) patients with malignant nodules. The ndings of our study also suggest that the presence of cervical lymphadenopathy is high in the presence of malignant thyroid nodules. Twenty-four of 35 (69%) malignant nodules had lymph node enlargement compared with only 2 of 100 (2%) benign nodules. According to the literature, STNs have a higher risk of malignancy than multiple nodules. [ 2] .
[28] Hence, multinodularity does not necessarily exclude malignancy, as seen by our study group.
Male sex, normal thyroid volume, single nodularity, nodule hypoechogenicity, and blurred margins were also associated with malignancy, but size was not signi cantly associated with malignancy [29].
We noted that male sex, microcalci cation, solid echogenicity of the nodule, and the presence of cervical lymphadenopathy were signi cantly associated with malignancy, as noted by Tai et al. [ 2]. Fine-needle aspiration cytology is recommended to be a cost-effective procedure in the initial assessment and management of thyroid nodules. [2,11] It is recommended that every patient with a palpable thyroid nodule should undergo FNAC. USG-guided FNAC can lower the occurrence of nondiagnostic smears. Whenever we had problems in preoperative diagnosis by FNAC due to inadequate material or di culty in aspiration by conventional methods, we repeated FNAC by USG guidance. In our study and previous study experience, noted a better yield of diagnostic cytological material with the help of USG-guided aspirations compared to blind FNAC. [ 31,32].
All our patients underwent FNAC by ultrasound guidance before surgery, as it helped us to decide the type of surgery to be undertaken. When the FNAC report was malignant or suspicious, total thyroidectomy was performed. In all other cases, hemithyroidectomy was performed, and a subsequent plan was decided based on a conclusive para n section report.
In a recent article, the authors emphasized the role of USG by suggesting that nodules with a nondiagnostic FNAC result in the setting of low-risk demographics and benign appearance at ultrasound can be followed with serial ultrasound examinations, thereby avoiding repeat FNAC. [ 33] These ndings are in contrast to the recommended current guidelines to repeat FNAC after a nondiagnostic result. [ 62].
Determining the nature of STNs is very important, as aggressive surgery may be regarded as an excessive mode of treatment. [ 2] We opted for surgery in all patients, as there is a high incidence of malignancy in STN patients, as reported in the literature. [ 2] The postoperative histopathology reports corroborated our ndings, as ~1/3 of STNs were reported to be malignant. study by Arul and  In our study, thyroid ne needle aspiration had a sensitivity, speci city, accuracy, positive predictive value, and negative predictive value of 61.33%, 71.66%, 64.44%, 73.1%, and 59.72%, respectively.
The sensitivity of FNA cytology in this study is low compared to published studies from outside countries where the sensitivity, speci city and accuracy of FNA cytology are more than 94%. which adversely affected the surgical decision making and the outcome. We should realise that negative FNA cytology does not exclude malignancy, and we have to seriously evaluate the situation and to rethink on how to raise the scale of sensitivity in FNA cytology in the diagnosis of thyroid nodules and to improve the level of expertise in cytology.
Yemen, as any developing country, lacks an accepted level of expertise in this eld, something that makes it mandatory to continuously monitor and evaluate how valid this procedure is. whose study reported . However, this high rate of malignancy is not surprising if we know that FNAC is currently routinely performed for most cases of thyroid nodules. This has led to a reduction in the number of unnecessary surgeries and consequently to a rise in the percentage reported for malignancy. [ 39].
The correlation between FNAC and histopathological diagnoses in our study shows the accuracy with which FNAC diagnosed follicular neoplasia. There were 14 cases of false negatives that had been reported as benign nodules by FNAC examination, and histopathological analysis showed follicular adenoma in 12 cases and hurthel adenoma in 2 cases and 8 cases of false positives (FPs), diagnosed as follicular neoplasms by FNAC examination. Histopathological analysis showed that two of them were colloid nodular goiters, one adenomatous nodule, one hyperplastic nodule, one toxic adenoma and three Hashimoto's thyroiditis (chronic lymphocytic thyroiditis Three patients (2.22%) had temporary unilateral recurrent laryngeal nerve injury and laryngeal edema, 2/35 (6%) patients had malignant nodules, and one/100 (1%) patient had benign nodules.

Conclusion
The incidence of malignancy in STNs is indeed high. Clinically detected solitary nodules should be treated with a high degree of suspicion. Male patient and rapid growth by history and hard xed nodules by clinical examination and hypoechoic, microcalci cation and cervical lymphadenopathy on USG were seen more frequently in malignant nodules. FNAC is more accurate and helpful for diagnosing solitary thyroid nodules if aspiration under USG guidance and reading by experience histopathology. The type of surgery depends on preoperative evaluation, including history, clinical examination, ultrasound, FNAC result, and intraoperative assessment of the nodule. Male sex was identi ed as a risk factor for thyroid cancer, while age, number and size of nodules were not. The most common indication for surgery was a diagnosis of malignant disease when preoperative FNAC and US were inconclusive. There were fewer complications of thyroid surgery by experienced surgeons.
Intraoperative assessment for hardness and xedity of nodules and decision for total thyroidectomy at that time reduced the need for a second operation, such as completion thyroidectomy and its complications.          [