What is the diagnosis and treatment for a 68-year-old patient with slight swelling between the jaw and ear, jaw pain, and a CT scan showing an enlarged heterogeneous multinodular thyroid gland and a tiny punctate calcification in the left parotid gland?

Diagnosis and Management of Jaw Swelling with Multinodular Thyroid Goiter

Primary Diagnosis

Your patient's jaw and ear swelling is most likely unrelated to the CT findings, as the scan shows no pathology in the parotid glands, salivary structures, or jaw that would explain the symptoms. The CT demonstrates an enlarged heterogeneous multinodular thyroid gland and a clinically insignificant 1mm parotid calcification, but no acute inflammatory process, mass, or fluid collection in the symptomatic area 1.

Interpretation of CT Findings

The Multinodular Thyroid Gland

• The enlarged heterogeneous multinodular thyroid is an incidental finding that requires systematic evaluation, not emergent intervention 1.
• The American College of Radiology recommends starting with thyroid function tests, particularly TSH, before proceeding with any additional thyroid imaging or intervention 1.
• The CT report references a recent thyroid ultrasound from [DATE] - you must review those results and recommendations first 1.

The Parotid Calcification

• The 1mm punctate calcification in the left parotid gland is clinically insignificant and does not explain the patient's symptoms 2.
• This tiny calcification is likely a sialolith or incidental finding unrelated to the presenting complaint 2.

Immediate Management Steps

For the Jaw/Ear Swelling and Pain

1. The negative CT effectively rules out serious pathology (abscess, malignancy, significant salivary obstruction) in the symptomatic area 2.
2. Consider non-imaging diagnoses:
   • Temporomandibular joint dysfunction (though TMJ appears unremarkable on CT)
   • Myofascial pain
   • Referred pain from dental issues (despite the dentist's assessment)
   • Viral parotitis or sialadenitis that has already improved
3. Conservative management is appropriate: observation, NSAIDs for pain, warm compresses if salivary etiology suspected 3.

For the Multinodular Thyroid Goiter

Step 1: Check TSH Level Immediately

• TSH is the single most important test to guide further thyroid evaluation 1.
• This determines whether the goiter is toxic (low TSH), nontoxic (normal TSH), or associated with hypothyroidism (high TSH) 1, 3.

Step 2: Review the Referenced Thyroid Ultrasound

• The CT report specifically directs you to recent thyroid ultrasound findings 1.
• Ultrasound provides superior morphological evaluation compared to CT for thyroid nodules 1.
• Look for ultrasound features suggesting malignancy: hypoechogenicity, microcalcifications, irregular borders, solid aspect, intranodular blood flow 4.

Step 3: Determine Need for Fine Needle Aspiration

• FNAB should be performed for any nodule >1 cm with suspicious ultrasound features 4.
• In multinodular goiter, nodules with suspicious ultrasound characteristics should undergo FNAB even if TSH is normal 4.
• The American College of Radiology states that radionuclide scanning has low positive predictive value for malignancy and does not help decide which nodules to biopsy in euthyroid patients 1.

Step 4: Management Based on TSH Results

If TSH is Normal (Nontoxic Multinodular Goiter):

• Yearly clinical observation with TSH monitoring is appropriate for asymptomatic patients 5.
• Assess for compressive symptoms: dyspnea, orthopnea, dysphagia, dysphonia 1.
• Surgery is indicated only if: compressive symptoms develop, cosmetic concerns, or malignancy risk based on FNAB 3, 5.
• Levothyroxine suppression therapy is controversial and often unsuccessful; avoid in patients with already suppressed TSH 5.

If TSH is Low (Toxic Multinodular Goiter):

• Radioiodine uptake scan should be performed to confirm autonomous function 1.
• Treatment options include radioactive iodine therapy or surgery 3, 5.
• Radioiodine is effective with 98% success rate for toxic nodules 1.

If TSH is High (Hypothyroidism):

• Imaging beyond what you already have is generally not indicated 1.
• Treat hypothyroidism medically 1.

Critical Pitfalls to Avoid

• Do not proceed directly to radioiodine uptake scan without checking TSH first - this wastes resources and has low diagnostic value in euthyroid patients 1.
• Do not use radionuclide scanning to determine malignancy risk - it has poor positive predictive value and does not replace ultrasound evaluation 1.
• Do not assume the multinodular goiter explains the jaw symptoms - the CT shows no connection between the thyroid and the symptomatic area 2.
• Do not overlook potential malignancy - there is at least an 11.3% prevalence of malignant or potentially malignant lesions among incidental thyroid abnormalities detected on CT 2.
• Do not start levothyroxine suppression therapy without clear indication - it is often ineffective for multinodular goiter and risks iatrogenic hyperthyroidism 5.

Malignancy Risk Assessment

• The overall rate of malignancy in incidentally detected thyroid abnormalities on CT is at least 3.9%, with an additional 7.4% showing malignant potential 2.
• Patients ≤35 years have significantly higher malignancy rates, though your 68-year-old patient falls outside this high-risk age group 2.
• CT cannot reliably distinguish benign from malignant thyroid lesions - ultrasound with selective FNAB is essential 2.
• Multiple ultrasound features of malignancy increase specificity, though each individual feature has poor predictive value 4.

Follow-Up Plan

Immediate (within 1 week):

• Order TSH level
• Review the thyroid ultrasound from [DATE]
• Reassess jaw/ear symptoms clinically

Short-term (2-4 weeks):

• Based on TSH results, proceed with appropriate thyroid imaging (radioiodine scan if TSH low) or FNAB (if nodules >1cm with suspicious features) 4, 1
• If jaw symptoms persist or worsen, consider ENT referral for direct visualization and possible sialendoscopy

Long-term:

• Annual TSH monitoring and clinical examination for nontoxic goiter 5
• Surgical consultation if compressive symptoms, cosmetic concerns, or confirmed/suspected malignancy develop 3, 5