BACKGROUND: Decisions involving the management of patients with papillary microcarcinoma are complex. Here we review and consider the literature in this area including two studies published in this issue of Thyroid. SUMMARY AND CONCLUSIONS: Thyroid nodules 5 mm or smaller have a high rate of false positive ultrasound findings and often yield inadequate cytology on fine needle aspiration biopsy (FNAB). We conclude that nodules of this size with no other clinical findings should not undergo routine FNAB, even if they appear ultrasonographically suspicious. Biopsying such small nodules evokes major patient anxiety and is likely to yield cytology that is insufficient for diagnosis, especially in the hands of inexperienced ultrasonographers. Periodic ultrasound examination, despite its shortcomings, is likely to be a better option for such patients since their small nodules may spontaneously disappear or fail to grow over time. Those that grow by at least 50% or more might be considered for FNAB, but only if they exceed 5 mm.