Diagnostic Imaging Pathways - Goitre (Investigation)
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This pathway provides guidance on the imaging of adult patients presenting with a goitre.
Date reviewed: January 2012
Date of next review: January 2015
Published: January 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Retrosternal Goitre Image 1a, b, c and d (Computed Tomography): The right lobe of the thyroid is considerably enlarged with retrosternal extension and deviation of the trachea to the left (arrows). There are a few mediastinal nodes which measure around 1cm in short axis diameter. |
| 1b |  |
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| 1c |  |
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| 1d |  |
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| 2a |  |
Multinodular (Colloid) Goitre
Image 2a: Total thyroidectomy showing a multinodular goitre with marked asymmetrical enlargement of the right lobe due to a massive dominant nodule. |
| 2b |  |
Image 2b (H&E, x2.5): Histological section of a multinodular (colloid) goitre showing the usual features of variously sized, colloid-containing follicles lined by uniform epithelial cells, patchy areas of haemorrhage and fibrosis. |
| 2c |  |
Image 2c (H&E, x10): Histological section of Graves' disease showing hyperplastic follicles with infolding of the follicular epithelium to form papillary projections (blue arrow). The colloid is pale with scalloped margins (green arrows). |
Teaching Points
Teaching Points
- A detailed history is required initially in the assessment of a potential goitre
- If there is evidence on history or examination of potential thoracic outlet compression, a CT is required for further evaluation
- If there is no evidence of thoracic outlet compression, thyroid function tests determine the biochemical significance of the goitre and guide further diagnostic imaging
ct
Computed Tomography (CT)
- Between 3% and 17% of goitres extend into the thorax, the majority being in the anterior mediastinum 7
- The use of contrast agents that contain iodine are best avoided because of the risk of inducing hyperthyroidism
- Although most patients are asymptomatic with an intrathoracic goitre, compression of the trachea may cause dyspnoea, wheezing or stridor 9
- CT is generally considered the investigation of choice for the investigation of suspected intrathoracic goitre, particularly because of the limited availability of MRI
- Most mediastinal thyroid tissue retains a connection to the cervical thyroid gland so images of the neck should also be performed 8
- Before the administration of intravenous contrast the attenuation of thyroid tissue exceeds that of other soft tissues of the neck and this characteristic helps distinguish thyroid masses from other types of mediastinal masses such as lymphoma 8
- After intravenous contrast administration thyroid tissue usually exhibits early and prolonged enhancement 8
us
Ultrasound
- Not routinely indicated in patients with a goitre 10
- However, in selected patients it may be useful to measure the volume of the thyroid gland and any response to treatment 1
- Various methods of estimating the volume of the thyroid gland with ultrasound have been proposed 2,3,4
- Although ultrasound is rarely used for suspected Graves' disease some studies have shown that thyroid vascularity and arterial blood flow are higher in patients with active disease 5,6
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Tessler FN, Tublin ME. Thyroid sonography: current applications and future directions. AJR Am J Roentgenol. 1999;173:437-43. (Review article)
- Langer P. Normal thyroid size versus goiter: post-mortem thyroid weight and ultrasonographic volumetry versus physical examination. Endocrinol Exp. 1989;23:67-76. (Review article)
- Ueda D. Sonographic measurement of the volume of the thyroid gland in healthy children. Acta Paediatr Jpn. 1989;31:352-4. (Level IV evidence)
- Szebeni A, Beleznay E. New simple method for thyroid volume determination by ultrasonography. J Clin Ultrasound. 1992;20:329-37. (Level III evidence)
- Castagnone D, Rivolta R, Rescalli S, et al. Color Doppler sonography in Graves' disease: value in assessing activity of disease and predicting outcome. AJR Am J Roentgenol. 1996;166:203-7. (Level III evidence)
- Baldini M, Castagnone D, Rivolta R, et al. Thyroid vascularization by color Doppler ultrasonography in Graves' disease: changes related to different phases and to the long-term outcome of the disease. Thyroid. 1997;7:823-8. (Level III evidence)
- Mack E. Management of patients with substernal goiters. Surg Clin North Am. 1995;75:377-94. (Review article)
- Glazer GM, Axel L, Moss AA. CT diagnosis of mediastinal thyroid. AJR Am J Roentgenol. 1982;138:495-8. (Level IV evidence)
- Madjar S, Weissberg D. Retrosternal goiter. Chest. 1995;108:78-82. (Level III evidence)
- Swaraj S. Thyroid enlargement: a more direct approach to investigation. Medicine Today. 2004;5:49-55. (Review article)
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Iodine-Containing Contrast Medium Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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