What imaging is recommended for a patient with a globus sensation after thyroidectomy?

Imaging for Post-Thyroidectomy Globus Sensation

Neck ultrasound is the first-line imaging modality recommended for patients experiencing globus sensation after thyroidectomy. 1, 2

Initial Evaluation

Globus sensation (feeling of a lump in the throat) is a common complaint after thyroidectomy, affecting more than half of patients within the first month after surgery 3. When evaluating a patient with post-thyroidectomy globus sensation, imaging should be performed to rule out structural causes such as:

• Residual thyroid tissue
• Recurrent disease
• Cervical lymphadenopathy
• Post-operative hematoma
• Other structural abnormalities

Imaging Algorithm

First-Line Imaging

• Neck Ultrasound: This is the primary imaging modality for evaluating the thyroid bed and cervical lymph nodes 1, 2
  • Advantages: Non-invasive, no radiation, excellent visualization of superficial neck structures
  • Can detect:
    • Residual thyroid tissue
    • Recurrent disease in the thyroid bed
    • Cervical lymphadenopathy
    • Post-operative fluid collections or hematoma

Second-Line Imaging (if ultrasound is inconclusive)

• CT Neck with contrast:

  • Indicated when ultrasound findings are equivocal or to better assess:
    • Central compartment lymph nodes (which have higher sensitivity on CT than ultrasound) 1
    • Retropharyngeal space involvement
    • Tracheal, esophageal, or vascular involvement
    • Mediastinal extension
  • Note: Modern evidence shows that iodinated contrast is not contraindicated for differentiated thyroid cancer patients 1

• MRI Neck:

  • Alternative to CT with similar indications
  • Particularly useful for evaluating soft tissue involvement
  • May be preferred in patients who cannot receive iodinated contrast

Additional Imaging (based on specific findings or concerns)

• Thyroglobulin measurement: Should be performed concurrently with imaging to assess for biochemical evidence of recurrence 2
• Whole-body scintigraphy: Only indicated if radioactive iodine (RAI) therapy was previously administered and there is concern for RAI-avid recurrent disease 1, 2
• FDG-PET/CT: Reserved for cases with elevated thyroglobulin but negative conventional imaging, suggesting possible RAI-refractory disease 1, 2

Clinical Considerations

Several factors increase the risk of developing globus symptoms after thyroidectomy:

• Female sex (2.6× higher risk)
• Central lymph node metastasis (3.5× higher risk)
• Central neck dissection (3.7× higher risk) 3

Interestingly, while some studies suggest thyroidectomy may worsen globus symptoms 3, others indicate it may actually improve them, particularly in patients with larger goiters (WHO grade 2 or greater) 4.

Follow-up Recommendations

• If initial imaging is negative but symptoms persist, consider:

  • Laryngopharyngeal sensory testing (though studies show the internal branch of the superior laryngeal nerve typically remains intact after thyroidectomy) 5
  • Evaluation for non-structural causes (e.g., psychological factors, esophageal motility disorders)

• For patients with differentiated thyroid cancer, regular surveillance should include:

  • Physical examination
  • Thyroglobulin measurement
  • Annual neck ultrasound 1, 2

Important Caveats

• Globus sensation after thyroidectomy is common and often multifactorial
• While imaging is essential to rule out structural causes, negative imaging does not exclude the possibility of functional or neurological causes
• Post-thyroidectomy hematoma, though rare, is a potentially life-threatening complication that should be ruled out in the early post-operative period 6
• Persistent globus sensation with a thyroid nodule on imaging could rarely indicate medullary thyroid carcinoma, which requires serum calcitonin testing 7