What are the steps to order an ultrasound of the thyroid?

How to Order an Ultrasound of the Thyroid

To order a thyroid ultrasound, request a comprehensive thyroid and cervical neck ultrasound with assessment of nodule characteristics including composition, echogenicity, margins, calcifications, and vascularity, along with evaluation of cervical lymph nodes. 1

Indications for Thyroid Ultrasound

Thyroid ultrasound is indicated in the following situations:

• Evaluation of thyroid nodules detected by palpation or incidentally on other imaging
• Assessment of nodules causing clinical symptoms such as compression or cosmetic concerns
• Nodules with maximal diameter ≥2cm
• Evaluation of autonomously functioning thyroid nodules
• Assessment of recurrent nodules after chemical ablation
• Monitoring of known thyroid disease
• Suspicious clinical features (firm nodule, fixed to adjacent structures, rapidly growing, associated lymphadenopathy, vocal cord paralysis) 2

Pre-Ultrasound Workup

Before ordering a thyroid ultrasound, consider the following:

• Measure serum TSH levels (ideally before proceeding to imaging) 2
• Perform a thorough clinical assessment for risk factors:
  • History of head and neck irradiation
  • Family history of thyroid cancer
  • Associated syndromes (MEN 2A/2B, familial adenomatous polyposis, Cowden's syndrome)
  • Age <15 years or male gender (higher risk of malignancy) 2

Ultrasound Order Specifications

When ordering a thyroid ultrasound, specify:

1. Clinical indication - clearly state the reason for the ultrasound (e.g., palpable nodule, follow-up of known nodule, etc.)
2. Examination type - request "Complete thyroid and central neck ultrasound" 2, 1
3. Areas to evaluate:
   • Thyroid gland (both lobes and isthmus)
   • Central neck compartment
   • Lateral neck compartment (if suspicious for malignancy)
   • Cervical lymph nodes 2, 1
4. Specific assessment requests:
   • Nodule characteristics (size, composition, echogenicity, margins, calcifications)
   • Vascularity assessment with color Doppler
   • TI-RADS risk stratification 1, 3

Additional Considerations

• For suspected malignancy, request assessment of:

  • Extrathyroidal extension
  • Relationship to adjacent structures (trachea, blood vessels)
  • Cervical lymphadenopathy 2

• For follow-up studies, include:

  • Previous ultrasound report date and findings
  • Specific nodules requiring reassessment
  • Request for comparison with prior studies 1

Post-Ultrasound Management

Based on ultrasound findings, further management may include:

• Fine-needle aspiration biopsy (FNAB) for:

  • Solid nodules >1cm with suspicious features
  • Any size nodule with highly suspicious features in high-risk patients 2, 1

• Follow-up ultrasound for:

  • Low-risk nodules (TI-RADS 2-3)
  • Benign nodules with interval growth 1

Common Pitfalls to Avoid

• Incomplete order information: Failure to specify clinical context can lead to inadequate assessment
• Overlooking lateral neck: Request evaluation of lateral neck compartments when there's suspicion of malignancy
• Ignoring prior studies: Always reference previous imaging for meaningful comparison
• Relying solely on size: Remember that ultrasound characteristics are more important than size alone in determining malignancy risk 1

Thyroid ultrasound is a cost-effective, radiation-free, and widely available imaging method that provides essential information about thyroid anatomy and pathology 4, 5. When properly ordered and interpreted, it serves as a cornerstone for thyroid nodule management.