The authors of this practical review paper highlight a growing issue within thyroid surgery, where high-quality ultrasound has increased the detection of subclinical nodules: what do we do with the patient presenting with an ‘incidental’ thyroid nodule? This has both implications for individual patients in terms of morbidity as well the real wider issue of optimising limited healthcare resources. To answer this conundrum, the authors undertook a literature review, including comparisons of several American, British and Korean guidelines. They look in detail at the evidence behind each element of nodule appearance on ultrasound. The overall result of the findings of this paper is a potentially useful algorithm. They emphasise the evidence base for the role of conservative management of nodules, citing that the increased incidence of thyroid cancer has not altered mortality rates. The algorithm advises what ultrasound features and clinical information to identify in patients with >1cm, >2cm and >4cm nodules respectively. To put this proposed algorithm in context, we can look at the two areas where the authors have highlighted that it differs from the American Thyroid Association; it is more conservative than the ATA in biopsying nodules >2cm that do not possess any malignant sonographic features but contain a solid component, regardless of echogenicity. It is more lenient compared with the ATA in regards to recommending FNAC in spongiform nodules >4cm. They cite that meta-analyses have shown particularly high odds-ratios and specificity for benign characterisation with spongiform ultrasound appearances. Ultimately, they propose that an algorithm such as this would augment a local/national guideline rather than replace it.