Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Overview of the clinical utility of ultrasonography in thyroid disease

Manfred Blum, MD, FACP
Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD


Although ultrasonography yields limited diagnostic information, it provides many highly valuable clinical insights that, when taken together, assemble exceedingly useful and pertinent information. This cumulative ultrasonography evidence, in context, can significantly augment diagnosis and clinical, surgical, radiation, ablation, and other management. High among the merits of ultrasonography is enhanced sampling of thyroid cells and tissues for cytological, biochemical, molecular, and genetic investigation in conjunction with fine-needle aspiration biopsy. Ultrasonography also offers insights into aspects of physiology and epidemiology.

Current methods of ultrasonography permit "real-time" identification of structures as small as 2 mm in diameter, thereby allowing the visualization of very small tumors of the thyroid and parathyroid glands. These methods also permit estimates of overall and regional blood flow to the thyroid. However, the results of thyroid ultrasonography do not correlate perfectly with histopathologic findings.

Although the cost effectiveness of ultrasonography in solving patient-specific clinical problems has not been formally tested, ultrasonography, used judiciously, helps to answer important clinical questions in specific patients. At present, ultrasonography is considered useful in the following situations:

To evaluate the anatomic features of thyroid nodules

To assist in fine-needle aspiration (FNA) of thyroid nodules and cervical lymph nodes

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Mar 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Singaporewalla RM, Hwee J, Lang TU, Desai V. Clinico-pathological Correlation of Thyroid Nodule Ultrasound and Cytology Using the TIRADS and Bethesda Classifications. World J Surg 2017.
  2. Cappelli C, Castellano M, Pirola I, et al. The predictive value of ultrasound findings in the management of thyroid nodules. QJM 2007; 100:29.
  3. Sipos JA. Advances in ultrasound for the diagnosis and management of thyroid cancer. Thyroid 2009; 19:1363.
  4. Moon WJ, Jung SL, Lee JH, et al. Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study. Radiology 2008; 247:762.
  5. Ito Y, Amino N, Yokozawa T, et al. Ultrasonographic evaluation of thyroid nodules in 900 patients: comparison among ultrasonographic, cytological, and histological findings. Thyroid 2007; 17:1269.
  6. Solbiati L, Volterrani L, Rizzatto G, et al. The thyroid gland with low uptake lesions: evaluation by ultrasound. Radiology 1985; 155:187.
  7. Cochand-Priollet B, Guillausseau PJ, Chagnon S, et al. The diagnostic value of fine-needle aspiration biopsy under ultrasonography in nonfunctional thyroid nodules: a prospective study comparing cytologic and histologic findings. Am J Med 1994; 97:152.
  8. Ito Y, Kobayashi K, Tomoda C, et al. Ill-defined edge on ultrasonographic examination can be a marker of aggressive characteristic of papillary thyroid microcarcinoma. World J Surg 2005; 29:1007.
  9. Park JS, Son KR, Na DG, et al. Performance of preoperative sonographic staging of papillary thyroid carcinoma based on the sixth edition of the AJCC/UICC TNM classification system. AJR Am J Roentgenol 2009; 192:66.
  10. Kakkos SK, Scopa CD, Chalmoukis AK, et al. Relative risk of cancer in sonographically detected thyroid nodules with calcifications. J Clin Ultrasound 2000; 28:347.
  11. Brunese L, Romeo A, Iorio S, et al. A new marker for diagnosis of thyroid papillary cancer: B-flow twinkling sign. J Ultrasound Med 2008; 27:1187.
  12. Jakobsen JA. Ultrasound contrast agents: clinical applications. Eur Radiol 2001; 11:1329.
  13. Kwak JY, Kim EK, Son EJ, et al. Papillary thyroid carcinoma manifested solely as microcalcifications on sonography. AJR Am J Roentgenol 2007; 189:227.
  14. Yoon DY, Lee JW, Chang SK, et al. Peripheral calcification in thyroid nodules: ultrasonographic features and prediction of malignancy. J Ultrasound Med 2007; 26:1349.
  15. Bonavita JA, Mayo J, Babb J, et al. Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? AJR Am J Roentgenol 2009; 193:207.
  16. Cappelli C, Pirola I, Cumetti D, et al. Is the anteroposterior and transverse diameter ratio of nonpalpable thyroid nodules a sonographic criteria for recommending fine-needle aspiration cytology? Clin Endocrinol (Oxf) 2005; 63:689.
  17. Papini E, Guglielmi R, Bianchini A, et al. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab 2002; 87:1941.
  18. Appetecchia M, Solivetti FM. The association of colour flow Doppler sonography and conventional ultrasonography improves the diagnosis of thyroid carcinoma. Horm Res 2006; 66:249.
  19. Yang GC, Fried KO. Most Thyroid Cancers Detected by Sonography Lack Intranodular Vascularity on Color Doppler Imaging: Review of the Literature and Sonographic-Pathologic Correlations for 698 Thyroid Neoplasms. J Ultrasound Med 2016; 36:89.
  20. Lai X, Liu M, Xia Y, et al. Hypervascularity is more frequent in medullary thyroid carcinoma: Compared with papillary thyroid carcinoma. Medicine (Baltimore) 2016; 95:e5502.
  21. Kiernan CM, Solórzano CC. Bethesda Category III, IV, and V Thyroid Nodules: Can Nodule Size Help Predict Malignancy? J Am Coll Surg 2017.
  22. Cavallo A, Johnson DN, White MG, et al. Thyroid Nodule Size at Ultrasound as a Predictor of Malignancy and Final Pathologic Size. Thyroid 2017; 27:641.
  23. Lim ST, Jeon YW, Suh YJ. The Prognostic Values of Preoperative Tumor Volume and Tumor Diameter in T1N0 Papillary Thyroid Cancer. Cancer Res Treat 2016.
  24. Blum M, Shenkman L, Hollander CS. The autonomous nodule of the thyroid: correlation of patient age, nodule size and functional status. Am J Med Sci 1975; 269:43.
  25. Erdoğan MF, Anil C, Cesur M, et al. Color flow Doppler sonography for the etiologic diagnosis of hyperthyroidism. Thyroid 2007; 17:223.
  26. Blum M. Evaluation of thyroid function: Sonography, computed tomography and magnetic resonance imaging. In: Principles and Practices of Endocrinology and Metabolism, Becker KL, Bilezikian JP, Bremner WJ, Hung W (Eds), Lippincott Williams and Wilkins, Philadelphia 1990. p.289.
  27. Shimamoto K, Satake H, Sawaki A, et al. Preoperative staging of thyroid papillary carcinoma with ultrasonography. Eur J Radiol 1998; 29:4.
  28. Stulak JM, Grant CS, Farley DR, et al. Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer. Arch Surg 2006; 141:489.
  29. Kouvaraki MA, Shapiro SE, Fornage BD, et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery 2003; 134:946.
  30. Chang DB, Yuan A, Yu CJ, et al. Differentiation of benign and malignant cervical lymph nodes with color Doppler sonography. AJR Am J Roentgenol 1994; 162:965.
  31. Choi MY, Lee JW, Jang KJ. Distinction between benign and malignant causes of cervical, axillary, and inguinal lymphadenopathy: value of Doppler spectral waveform analysis. AJR Am J Roentgenol 1995; 165:981.
  32. Leboulleux S, Girard E, Rose M, et al. Ultrasound criteria of malignancy for cervical lymph nodes in patients followed up for differentiated thyroid cancer. J Clin Endocrinol Metab 2007; 92:3590.
  33. Kessler A, Rappaport Y, Blank A, et al. Cystic appearance of cervical lymph nodes is characteristic of metastatic papillary thyroid carcinoma. J Clin Ultrasound 2003; 31:21.
  34. Seven H, Gurkan A, Cinar U, et al. Incidence of occult thyroid carcinoma metastases in lateral cervical cysts. Am J Otolaryngol 2004; 25:11.
  35. Wunderbaldinger P, Harisinghani MG, Hahn PF, et al. Cystic lymph node metastases in papillary thyroid carcinoma. AJR Am J Roentgenol 2002; 178:693.
  36. Giovagnorio F, Drudi FM, Fanelli G, et al. Fatty changes as a misleading factor in the evaluation with ultrasound of superficial lymph nodes. Ultrasound Med Biol 2005; 31:1017.
  37. Pisani T, Vecchione A, Sinopoli NT, et al. Cytological and immunocytochemical analysis of laterocervical lymph nodes in patients with previous thyroid carcinoma. Anticancer Res 1999; 19:3527.
  38. Simeone JF, Daniels GH, Hall DA, et al. Sonography in the follow-up of 100 patients with thyroid carcinoma. AJR Am J Roentgenol 1987; 148:45.
  39. Arora, P, Blum, M. Utility of ultrasonography in post surgical management of patients with thyroid carcinoma. American Thyroid Association: Seventy-fourth Meeting, Washington, DC 2001.
  40. Ahuja AT, Ying M, Yuen HY, Metreweli C. Power Doppler sonography of metastatic nodes from papillary carcinoma of the thyroid. Clin Radiol 2001; 56:284.
  41. Alzahrani AS, Alsuhaibani H, Salam SA, et al. Diagnostic accuracy of high-resolution neck ultrasonography in the follow-up of differentiated thyroid cancer: a prospective study. Endocr Pract 2005; 11:165.
  42. Pacini F, Molinaro E, Castagna MG, et al. Recombinant human thyrotropin-stimulated serum thyroglobulin combined with neck ultrasonography has the highest sensitivity in monitoring differentiated thyroid carcinoma. J Clin Endocrinol Metab 2003; 88:3668.
  43. Torlontano M, Crocetti U, D'Aloiso L, et al. Serum thyroglobulin and 131I whole body scan after recombinant human TSH stimulation in the follow-up of low-risk patients with differentiated thyroid cancer. Eur J Endocrinol 2003; 148:19.
  44. Torlontano M, Crocetti U, Augello G, et al. Comparative evaluation of recombinant human thyrotropin-stimulated thyroglobulin levels, 131I whole-body scintigraphy, and neck ultrasonography in the follow-up of patients with papillary thyroid microcarcinoma who have not undergone radioiodine therapy. J Clin Endocrinol Metab 2006; 91:60.
  45. Chung YE, Kim EK, Kim MJ, et al. Suture granuloma mimicking recurrent thyroid carcinoma on ultrasonography. Yonsei Med J 2006; 47:748.
  46. Kim JH, Lee JH, Shong YK, et al. Ultrasound features of suture granulomas in the thyroid bed after thyroidectomy for papillary thyroid carcinoma with an emphasis on their differentiation from locally recurrent thyroid carcinomas. Ultrasound Med Biol 2009; 35:1452.
  47. Chung WY, Chang HS, Kim EK, Park CS. Ultrasonographic mass screening for thyroid carcinoma: a study in women scheduled to undergo a breast examination. Surg Today 2001; 31:763.
  48. Imaizumi M, Usa T, Tominaga T, et al. Long-term prognosis of thyroid nodule cases compared with nodule-free controls in atomic bomb survivors. J Clin Endocrinol Metab 2005; 90:5009.
  49. Marqusee E, Benson CB, Frates MC, et al. Usefulness of ultrasonography in the management of nodular thyroid disease. Ann Intern Med 2000; 133:696.
  50. Tollin SR, Mery GM, Jelveh N, et al. The use of fine-needle aspiration biopsy under ultrasound guidance to assess the risk of malignancy in patients with a multinodular goiter. Thyroid 2000; 10:235.
  51. Ota H, Ito Y, Matsuzuka F, et al. Usefulness of ultrasonography for diagnosis of malignant lymphoma of the thyroid. Thyroid 2006; 16:983.
  52. Bauer M, Blumentritt H, Finke R, et al. Using ultrasonography to determine thyroid size and prevalence of goiter in lithium-treated patients with affective disorders. J Affect Disord 2007; 104:45.
  53. Marcocci C, Vitti P, Cetani F, et al. Thyroid ultrasonography helps to identify patients with diffuse lymphocytic thyroiditis who are prone to develop hypothyroidism. J Clin Endocrinol Metab 1991; 72:209.
  54. Hayashi N, Tamaki N, Konishi J, et al. Sonography of Hashimoto's thyroiditis. J Clin Ultrasound 1986; 14:123.
  55. Gutekunst R, Hafermann W, Mansky T, Scriba PC. Ultrasonography related to clinical and laboratory findings in lymphocytic thyroiditis. Acta Endocrinol (Copenh) 1989; 121:129.
  56. Pedersen OM, Aardal NP, Larssen TB, et al. The value of ultrasonography in predicting autoimmune thyroid disease. Thyroid 2000; 10:251.
  57. Shahbazian HB, Sarvghadi F, Azizi F. Ultrasonographic characteristics and follow-up in post-partum thyroiditis. J Endocrinol Invest 2005; 28:410.
  58. Ralls PW, Mayekawa DS, Lee KP, et al. Color-flow Doppler sonography in Graves disease: "thyroid inferno". AJR Am J Roentgenol 1988; 150:781.
  59. Hodgson KJ, Lazarus JH, Wheeler MH, et al. Duplex scan-derived thyroid blood flow in euthyroid and hyperthyroid patients. World J Surg 1988; 12:470.
  60. Fobbe F, Finke R, Reichenstein E, et al. Appearance of thyroid diseases using colour-coded duplex sonography. Eur J Radiol 1989; 9:29.
  61. Ota H, Amino N, Morita S, et al. Quantitative measurement of thyroid blood flow for differentiation of painless thyroiditis from Graves' disease. Clin Endocrinol (Oxf) 2007; 67:41.
  62. Anderson L, Middleton WD, Teefey SA, et al. Hashimoto thyroiditis: Part 1, sonographic analysis of the nodular form of Hashimoto thyroiditis. AJR Am J Roentgenol 2010; 195:208.
  63. Anderson L, Middleton WD, Teefey SA, et al. Hashimoto thyroiditis: Part 2, sonographic analysis of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis. AJR Am J Roentgenol 2010; 195:216.
  64. Eaton SE, Euinton HA, Newman CM, et al. Clinical experience of amiodarone-induced thyrotoxicosis over a 3-year period: role of colour-flow Doppler sonography. Clin Endocrinol (Oxf) 2002; 56:33.
  65. Bogazzi F, Bartalena L, Brogioni S, et al. Color flow Doppler sonography rapidly differentiates type I and type II amiodarone-induced thyrotoxicosis. Thyroid 1997; 7:541.
  66. Macedo TA, Chammas MC, Jorge PT, et al. Differentiation between the two types of amiodarone-associated thyrotoxicosis using duplex and amplitude Doppler sonography. Acta Radiol 2007; 48:412.
  67. Loy M, Perra E, Melis A, et al. Color-flow Doppler sonography in the differential diagnosis and management of amiodarone-induced thyrotoxicosis. Acta Radiol 2007; 48:628.
  68. Wong R, Cheung W, Stockigt JR, Topliss DJ. Heterogeneity of amiodarone-induced thyrotoxicosis: evaluation of colour-flow Doppler sonography in predicting therapeutic response. Intern Med J 2003; 33:420.
  69. Ota H, Ito Y, Matsuzuka F, et al. Usefulness of ultrasonography for diagnosis of malignant lymphoma of the thyroid. Thyroid 2006; 16:983.
  70. Blum M, Passalaqua AM, Sackler JP, Pudlowski R. Thyroid echography of subacute thyroiditis. Radiology 1977; 125:795.
  71. Hiromatsu Y, Ishibashi M, Miyake I, et al. Color Doppler ultrasonography in patients with subacute thyroiditis. Thyroid 1999; 9:1189.
  72. Kunz A, Blank W, Braun B. De Quervain's subacute thyroiditis -- colour Doppler sonography findings. Ultraschall Med 2005; 26:102.
  73. Park SY, Kim EK, Kim MJ, et al. Ultrasonographic characteristics of subacute granulomatous thyroiditis. Korean J Radiol 2006; 7:229.
  74. Lu CP, Chang TC, Wang CY, Hsiao YL. Serial changes in ultrasound-guided fine needle aspiration cytology in subacute thyroiditis. Acta Cytol 1997; 41:238.
  75. Miccoli P, Minuto MN, Galleri D, et al. Extent of surgery in thyroglossal duct carcinoma: reflections on a series of eighteen cases. Thyroid 2004; 14:121.
  76. Sierra M, Sebag F, De Micco C, et al. [Abrikossoff tumor of the proximal esophagus misdiagnosed as a thyroid nodule]. Ann Chir 2006; 131:219.
  77. Milas M, Mensah A, Alghoul M, et al. The impact of office neck ultrasonography on reducing unnecessary thyroid surgery in patients undergoing parathyroidectomy. Thyroid 2005; 15:1055.
  78. Chung SY, Oh KK, Chang HS. Sonographic findings of tuberculous thyroiditis in a patient with Behçet's syndrome. J Clin Ultrasound 2002; 30:184.
  79. Karwowski JK, Jeffrey RB, McDougall IR, Weigel RJ. Intraoperative ultrasonography improves identification of recurrent thyroid cancer. Surgery 2002; 132:924.
  80. Solorzano CC, Carneiro DM, Ramirez M, et al. Surgeon-performed ultrasound in the management of thyroid malignancy. Am Surg 2004; 70:576.
  81. Casadei R, Perenze B, Vescini F, et al. Usefulness of the ultrasonically activated shears in total thyroidectomy. Chir Ital 2004; 56:843.
  82. Makani S, Kim W, Gaba AR. Struma Ovarii with a focus of papillary thyroid cancer: a case report and review of the literature. Gynecol Oncol 2004; 94:835.
  83. Ranzini AC, Ananth CV, Smulian JC, et al. Ultrasonography of the fetal thyroid: nomograms based on biparietal diameter and gestational age. J Ultrasound Med 2001; 20:613.
  84. Luton D, Le Gac I, Vuillard E, et al. Management of Graves' disease during pregnancy: the key role of fetal thyroid gland monitoring. J Clin Endocrinol Metab 2005; 90:6093.
  85. Cohen O, Pinhas-Hamiel O, Sivan E, et al. Serial in utero ultrasonographic measurements of the fetal thyroid: a new complementary tool in the management of maternal hyperthyroidism in pregnancy. Prenat Diagn 2003; 23:740.
  86. Morine M, Takeda T, Minekawa R, et al. Antenatal diagnosis and treatment of a case of fetal goitrous hypothyroidism associated with high-output cardiac failure. Ultrasound Obstet Gynecol 2002; 19:506.
  87. Agrawal P, Ogilvy-Stuart A, Lees C. Intrauterine diagnosis and management of congenital goitrous hypothyroidism. Ultrasound Obstet Gynecol 2002; 19:501.
  88. Perry RJ, Hollman AS, Wood AM, Donaldson MD. Ultrasound of the thyroid gland in the newborn: normative data. Arch Dis Child Fetal Neonatal Ed 2002; 87:F209.
  89. Yasumoto M, Inoue H, Ohashi I, et al. Simple new technique for sonographic measurement of the thyroid in neonates and small children. J Clin Ultrasound 2004; 32:82.
  90. Kreisner E, Camargo-Neto E, Maia CR, Gross JL. Accuracy of ultrasonography to establish the diagnosis and aetiology of permanent primary congenital hypothyroidism. Clin Endocrinol (Oxf) 2003; 59:361.
  91. Knudsen N, Bols B, Bülow I, et al. Validation of ultrasonography of the thyroid gland for epidemiological purposes. Thyroid 1999; 9:1069.
  92. Semiz S, Senol U, Bircan, et al. Correlation between age, body size and thyroid volume in an endemic area. J Endocrinol Invest 2001; 24:559.
  93. Kaloumenou I, Alevizaki M, Ladopoulos C, et al. Thyroid volume and echostructure in schoolchildren living in an iodine-replete area: relation to age, pubertal stage, and body mass index. Thyroid 2007; 17:875.
  94. Yazici B, Simsek E, Erdogmus B, et al. Evaluation of the thyroid blood flow with Doppler ultrasonography in healthy school-aged children. Eur J Radiol 2007; 63:286.
  95. Drozd V, Polyanskaya O, Ostapenko V, et al. Systematic ultrasound screening as a significant tool for early detection of thyroid carcinoma in Belarus. J Pediatr Endocrinol Metab 2002; 15:979.
  96. Gurleyik E, Coskun O, Aslaner A. Clinical importance of solitary solid nodule of the thyroid in endemic goiter region. Indian J Med Sci 2005; 59:388.
  97. Kopecky KJ, Onstad L, Hamilton TE, Davis S. Thyroid ultrasound abnormalities in persons exposed during childhood to 131I from the Hanford nuclear site. Thyroid 2005; 15:604.
Topic Outline