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Head & Neck

 

Clinical imaging queries can be emailed to the radiology advice and guidance service. This is checked daily by one of the radiology consultants: rch-tr.GPRadiologyEnquiries@nhs.net

 

Background

GP direct access ultrasound (USS) for head and neck imaging very rarely yields a diagnosis of malignancy. However, incidental findings are detected within the thyroid in a significant proportion of referrals, up to 17% on local audit. The consequences of these incidental findings may include unnecessary further investigation and intervention for benign nodules and clinically insignificant indolent small papillary thyroid cancers, as well as generating increased patient anxiety1-3.

 

When should Head & Neck USS not be requested by primary care

Direct access imaging generally will NOT change management in the following clinical scenarios and should be avoided:

 


Thyroglossal duct cyst

Clinical features:

  • Often asymptomatic
  • Mobile midline neck mass at/below level of hyoid bone
  • Mass will elevate with tongue protrusion or swallowing

 

Referral pathway:

Where you are confident that the neck lump fits the above clinical picture, in a patient without any red flag features, you should:

  • Firstly, request a routine Neck USS
  • Then, refer routinely to the ENT Head & Neck service once the diagnosis is confirmed

Of course, other neck lumps can present similarly, therefore if there is any diagnostic uncertainty, please refer as per the ‘Neck Lump’ pathway.

 

Globus sensation

  • Subjective feeling of a lump in the throat
  • This clinical presentation does not benefit from USS; malignant pathology is almost never demonstrated1-4   (Globus Sensation guideline here)

 

Posterior neck pain

  • This clinical presentation does not benefit from USS; malignant pathology is almost never demonstrated1-4

 

Anterior neck pain

  • Direct access ultrasound is generally not indicated
  • If sialadenitis is a suspected cause, consider referral (see Neck Lump guideline here)
  • If thyroiditis is a suspected cause, see Thyroiditis guideline here


 

Clinically benign lymphadenopathy

  • Routine imaging does not alter management
  • Referral guidance is available here

 

Salivary gland pathology      

  • Direct access USS is not indicated in the initial investigation
  • Referral guidance for suspected benign and malignant salivary gland pathology is available here

 

Thyroid disorders

  • Unexplained thyroid mass raising the suspicion of malignancy should be referred through the ENT 2WW pathway, where same day imaging +/- FNA is available, if deemed appropriate. USS is not required before referral.
  • Direct access imaging is not indicated in primary care as part of the investigation of hypothyroidism or hyperthyroidism. Hypothyroidism guidelines are available here. Hyperthyroidism guidelines are available here.
  • Established, unchanged thyroid nodule or goitre in the absence of risk factors* does not require routine surveillance. Imaging does not alter management. *Risk factors for malignancy include a history of neck irradiation and family history of thyroid cancer.
  • In cases of incidental thyroid nodules demonstrating atypical or potentially malignant features, the clinical imaging report will make this clear and provide recommendations for further action.

 

Parathyroid disorders

 

Palpable lumps arising from the skine.g. sebaceous cyst / acne

  • Direct access USS is not indicated
  • Guidelines for management of benign skin lesions is available here

 

Craniofacial soft tissue masses arising from the nose, orbits and pinna

  • Direct access USS is not indicated in the initial investigation
  • Good transducer contact is often difficult
  • Consider referral to the appropriate specialty if there is diagnostic uncertainty

 

Lipoma

  • Guidelines for management of lipoma are available here

 

 

Red flags

Refer via ENT 2WW if: 

  • Previously un-investigated, unexplained PALPABLE lump in the neck (including thyroid, parotid and submandibular glands)
     
  • Unexplained persistent (>4 weeks) sore or painful throat (especially with otalgia)                                                                                          
    (NOT for globus or throat discomfort)

  • Persistent (>3weeks) unexplained hoarseness and age ≥ 45yrs

 

 

References

  1. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours BMJ 2013;347:f4706 27 August 2013
  2. British Thyroid Association Guidelines for the Management of Thyroid Cancer. Clinical Endocrinology Vol 81 Sup 1 July 2014
  3. Local audit. Contact benjamin.rock@nhs.net if further information required.
  4. Justification of Ultrasound Requests. British Medical Ultrasound Society Professional Standard Group June 2015 V1

 

 

Review date                          January 2022

Next review date                   January 2023

GP Sifter                               Dr Laura Vines

Contributors                          Dr Ben Rock, Consultant Radiologist

                                              Mr Venkat Reddy, Consultant ENT Surgeon

Version                                  2.0