B
B. Neck 

Soft tissues

CLINICAL/DIAGNOSTIC

PROBLEM

INVESTIGATION

RECOMMENDATION

(GRADE) 

COMMENT

DOSE

Thyroid nodules

US

Indicated only in specific circumstances (B)

US is excellent for differentiating between thyroid and extrathyroid masses, for guiding aspiration or biopsy (particularly in difficult-to-palpate or small thyroid nodules), and for the detection of associated lymphadenopathy in thyroid malignancy.  While US can be specific for malignancy, it has poor sensitivity.  In generalised thyroid enlargement or multinodular goitre US readily shows retrosternal extension; real-time studies show effect of neck extension, etc.  CT/ MRI is needed to demonstrate full retrosternal extent and tracheal compromise.  NM has no role in the initial evaluation of thyroid nodules.

0
US-guided FNAC/FNAC Indicated (B)

Thyroid nodules are extremely common; the majority are benign.  Conventional fine-needle aspiration (FNAC) (without imaging) is the most cost-effective initial investigation.

0/0
 
Thyrotoxicosis NM Indicated NM can differentiate between Graves' disease, toxic nodular goitre, and subacute thyroiditis.  Provides functional information about nodules.  Also useful in thyroiditis. II
 
Ectopic thyroid tissue (e.g. lingual thyroid) NM Indicated (C) NM excellent for small ectopic rests of thyroid tissue. II
 
Hyperparathyroidism US/NM/CT/MRI Specialised investigation (C) Seek advice.  Diagnosis made on clinical/biochemical grounds.  Imaging can assist in pre-operative localisation but may not be needed by experienced surgeons.  Much depends on local policy and available technology and expertise.  US, NM, CT, and MRI are all accurate in the un-operated neck.  MRI is probably evolving as the best investigation for ectopic and residual tumours.  Super-selective venography for sampling after previous imaging may be useful. 0/II/II/0
 
Asymptomatic carotid bruit US carotids Indicated only in specific circumstances (B) US not usually valuable as evidence suggests that surgery is not recommended for asymptomatic carotid stenosis. 0
 
Swallowed or inhaled foreign body

 

(For children see section M)

 Lateral XR sort tissues of neck Indicated only in specific circumstances (B) The majority of foreign bodies are not seen on XR.  The clinical history and findings are more accurate indicators of the presence of a foreign body.  Direct examination of the oropharynx, laryngoscopy, and endoscopy are the investigations of choice. I
 
Neck mass of unknown origin US Indicated (C) First-line investigation for characterisation of neck mass. May be combined with FNAC 0
CT/MRI Indicated only in specific circumstances (C) CT/MRI may be indicated if full extent of the lesion is not determined by US, for identifying other lesions, and for staging. II/0
 
Salivary obstruction US/Sialogram Indicated (c) For intermittent, food-related swelling. MR sialography may be preferred in some centres. 0/II
XR Indicated only in specific circumstances (C) Where there is a calculus in the floor of the mouth, XR may be all that is required. I
 
Salivary mass US Indicated (C) US is the initial investigation of choice for a suspected salivary mass; it can be combined with FNAC, if necessary. It is extremely sensitive and has high specificity. 0
MRI/CT Specialised investigation (B) Whenever deep lobe involvement or extension into deep spaces is suspected, MRI or CT should be carried out 0/II
 
Dry mouth: connective tissue disease US/sialogram/NM Specialised investigation (C) Not commonly required. Sialogram may be diagnostic, but NM provides better functional assessment. MR sialography is also used here. 0/II/II
         
Temporomandibular joint dysfunction MRI Specialised investigation (B) XRs do not often add information as the majority of temporomandibular joint problems are due to soft tissue dysfunction (usually subluxation of the intra-articular disk) rather than bony changes, which appear late and are often absent in the acute phase. 0
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