What are the next steps for a 25-year-old patient with unilateral neck pain and a normal thyroid ultrasound?

Management of Right-Sided Neck Pain in a 25-Year-Old with Normal Thyroid Ultrasound

For a 25-year-old patient with right-sided neck pain and a normal thyroid ultrasound, the next step should be MRI of the cervical spine without contrast to evaluate for potential musculoskeletal causes, while also performing a thorough examination for any neck masses or lymph nodes that might indicate other pathology. 1

Initial Assessment

• Perform a comprehensive neck examination to distinguish between musculoskeletal pain and potential neck mass or lymphadenopathy 1
• Assess for "red flags" that would necessitate urgent evaluation, including:
  • Fever >101°F, unexplained weight loss, or difficulty swallowing 1
  • Neurological symptoms such as weakness, numbness, or radiating pain 1
  • Tenderness over vertebral bodies or intractable pain despite therapy 1

Diagnostic Approach

If Musculoskeletal Pain is Suspected:

• Cervical radiographs (X-rays) are appropriate as first-line imaging for initial assessment of suspected musculoskeletal neck pain 1
• If radiographs show degenerative changes but symptoms persist or worsen, MRI cervical spine without contrast is recommended as the next step 1, 2
• Remember that degenerative findings on imaging are common in asymptomatic individuals and correlate poorly with symptoms 1, 2

If Neck Mass is Suspected Despite Normal Thyroid Ultrasound:

• Palpate the neck thoroughly for masses - nontender masses are more concerning for malignancy than tender ones 1
• Examine the oropharynx with bright light and tongue depressor to identify any potential primary lesions 1
• Consider additional ultrasound evaluation of cervical lymph nodes if any are palpable 3
• Follow up weekly to monitor any palpable mass for changes in size 1

Treatment Algorithm

1. For simple musculoskeletal pain without red flags:

   • Conservative management with NSAIDs and physical therapy 1
   • Monitor symptoms for 4-6 weeks, as many cases resolve spontaneously 1

2. If pain persists beyond 4-6 weeks or worsens:

   • Obtain MRI cervical spine without contrast 1, 2
   • MRI is superior to CT for evaluating soft tissue abnormalities that may contribute to neck pain 1

3. If any concerning features develop during follow-up:

   • New or enlarging neck mass
   • Neurological symptoms
   • Systemic symptoms (fever, weight loss)
   • Proceed directly to MRI and/or specialist referral 1

Important Considerations

• Most cases of neck pain in young adults are musculoskeletal in origin and self-limiting 4
• The normal thyroid ultrasound has ruled out thyroid pathology, but doesn't exclude other potential causes of neck pain 3
• Be aware of normal anatomic structures that can be mistaken for pathologic neck masses, including submandibular glands, hyoid bone, transverse process of C2, and carotid bulb 1
• Psychosocial factors such as depressed mood and high role conflict are strong risk factors for neck pain and should be addressed if present 4

Follow-up Recommendations

• Schedule follow-up in 2-4 weeks if symptoms persist 2
• Instruct the patient to return sooner if they develop any red flag symptoms or if pain significantly worsens 1
• Consider referral to physical therapy for persistent musculoskeletal neck pain 1