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The evaluation of the patient with thyroid and/or parathyroid pathology is increasingly multimodal and includes history and physical examination, laboratory evaluation, and adjunctive radiologic studies. In particular, ultrasound has become an extension of the physical examination for patients with endocrine diseases of the neck and is often the first step in a radiologic evaluation of neck pathology. In fact, ultrasound is so ubiquitous that it is now commonly performed in the outpatient office setting and can provide immediate information that expedites diagnosis and treatment. Even when a patient presents for consultation with reports from prior ultrasound studies, a real-time sonography can confirm findings in addition to providing an opportunity for immediate image-guided biopsy. Ultrasound of the neck has become such a critical tool for the surgeon that the American College of Surgeons has determined that every surgical practice should include a “working knowledge of ultrasound of the head and neck.” Surgeons are typically asked to see a subset of patients with neck pathology. As such, this chapter will address primarily ultrasound for thyroid nodules/multinodular goiter, parathyroid disease, and pathologic lymphadenopathy.


Indications for neck ultrasonography by the surgeon include:


  • Thyroid
    • To delineate the presence, absence, size, and echo-characteristics of thyroid nodules/pathology
    • To differentiate between solid and cystic lesions
    • To delineate ultrasound characteristics that raise the risk of thyroid cancer in thyroid nodules (irregular borders, microcalcifications, hypoechogenicity, hypervascularity)
    • To detect concomitant pathology (lymph node disease, parathyroid disease, etc)
    • To identify the presence or absence of a substernal component, superior extension, or tracheal deviation from a goiter
    • To follow the progression, regression, or stability of thyroid disease
    • To identify characteristic findings of thyroid disease (ie, Hashimoto thyroiditis)
    • To assist in post-thyroidectomy surveillance for thyroid cancer recurrence (ie, thyroid remnant, lymph node recurrence)
    • To plan the location of the incision for surgery
  • Parathyroid
    • To identify and localize parathyroid adenoma(s) or hyperplasia
    • To detect concomitant pathology (lymph node disease, thyroid disease, etc)
    • To plan the location of the incision for surgery
  • Lymph nodes
    • To delineate the presence or absence of pathologic/benign lymph nodes as well as their precise locations
    • To detect concomitant pathology (thyroid disease, parathyroid disease, etc)
    • To plan the location of the incision for surgery
  • Interventions
    • To assist in fine needle biopsy of thyroid nodules, parathyroid glands, and/or lymph nodes
    • To assist in core needle biopsy of thyroid nodules/lymph nodes
    • To guide percutaneous treatments such as radiofrequency ablation, ethanol ablation, etc.


The vast number of structures in the neck can make mastery of neck ultrasound seem a daunting task, but the heterogeneity of those structures makes interpretation easier to learn. The superficial location of the soft tissue components of the anterior neck, as well as today’s high-frequency probes, allows physicians to study and delineate the anatomy of the neck clearly and with confidence.


The neck is divided into the lateral and central neck compartments. The central neck comprises the structures anterior to the paraspinous muscles and between the ...

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