The Neck (section 2)

(For The Spine See Sections 3 [The Spine] & 11 [Trauma])

CLINICAL PROBLEM

INVESTIGATION

RECOMMENDATION
{GRADE}

COMMENT
Soft Tissues
Thyroid nodules 201 US Indicated only in specific circumstances [B] Us is excellent for differentiating between thyroid and extra-thyroid masses, for guiding aspiration or biopsy (particularly in difficult to palpate or small thyroid nodules) and for the detection of associated lymphadenopathy or 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 etc. CT/MRI is needed to demonstrate full retrosternal extent and tracheal compromise. NM has no role in the initial evaluation of thyroid nodules.
US guided 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
Thyrotoxicosis 202 NM Indicated [B] NM can differentiate between Graves' disease, toxic nodular goitre and sub acute thyroiditis. Provides functional information about nodules. Also useful in thyroiditis.
Ectopic thyroid tissue (e.g. lingual thyroid) 203 NM Indicated [C] NM excellent for small ectopic rests of thyroid tissue.
Hyperparathyroidism 204 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 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
Asymptomatic carotid bruit 205 US carotids Indicated only in specific circumstances. [B] US not usually valuable as evidence suggests that surgery is not recommended for asymptomatic carotid stenosis.
Swallowed or inhaled foreign body (FB)

(see also 1127-1129) for children see section M)

 206 Lateral XR soft 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.

(for swallowed or inhaled FB in children see 1326 and 1331)
Neck mass of unknown origin 207 US Indicated [C] First line investigation for characterisation of neck mass. May be combined with FNAC
CT/MRI Indicated only in specific circumstances [C] CT/MRI may be indicated if the full extent of the lesion is not determined by US, for identifying other lesions and for staging.
Salivary obstruction 208 US / Sialogram Indicated [C] For intermittent, food related swelling. MR Sialography may be preferred in some centres.
XR Indicated only in specific circumstances [C] Where the is calculus in the floor of the mouth, XR may be all that is required.
Salivary mass 209 US Indicated [B] 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
MRI/CT Specialised investigation [B] Whenever deep lobe involvement or extension into deep spaces is suspected, MRI or CT should be carried out.
Dry mouth : connective tissue disease 210 US / Sialogram / NM Specialised investigation [C] Not commonly required. Sialogram may be diagnostic but NM provides better functional assessment. MR sialography also used here.
Temporo-mandibular joint dysfunction 211 MRI Specialised investigation [B] XRs do not often add information as the majority of tempromandibular joint problems are due to soft tissue dysfunction 9usually subluxation of the intra-articular disk) rather than bony changes, which appear late and are often absent in the acute phase.

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