The vast majority of patients presenting to a surgical practice have had prior ultrasound evaluations. Findings on that study often prompted the surgical consultation. It is essential to review those prior reports and images so as to fully understand the issues to address at that consultation as well as to better hone in on what needs to be evaluated during that office ultrasound.

Patients typically come into the office very concerned that there have been untoward changes in their thyroid and are typically told that they need biopsy and/or surgery. I find it quite useful at the completion of the ultrasound examination to show the patient their findings in real time on the ultrasound screen. This provides better reassurance, typically, that intervention is not required at this point and gives them an understanding as to any discrepancy between prior imaging and the current evaluation. To reassure these patients that important findings have not been overlooked, I will typically see them back for a follow-up evaluation. To this end, it is extremely useful to have the ability to capture images into the hospitals electronic medical record. This is key for image comparison both on a follow-up office visit and in the operating room.

The technique and conduct of the ultrasound evaluation is key for extracting the maximal amount of information from the examination and arriving at the proper clinical decision. Although aware of prior examination and imaging findings, it is important to keep an open and unprejudiced frame of mind while conducting the examination. Prior documentation of a benign thyroid nodule by FNA should not dissuade careful examination of the contralateral lobe nor of lymph nodes demonstrating worrisome sonographic features. Parathyroid adenomas may occasionally be identified in patients without prior suspicion of primary hyperparathyroidism.

In performing a thyroid ultrasound, it is important to conduct the examination in a standard fashion as well as to perform image capture and annotation systematically. There is no absolute right or wrong way to form this study, but establishing a routine will guarantee that a thorough examination has been performed and that essential elements are not omitted due to attention being focused on a major finding. It is also essential to understand that although we may use the term “thyroid” ultrasound , what this means in the surgeon’s office is a comprehensive neck ultrasound. Although our initial attention may be directed at a thyroid nodule that prompted surgical consultation, careful evaluation must be performed of the contralateral lobe, potential cervical adenopathy or other unexpected anatomic findings that may be key to directing needle aspiration or indication for surgery.

I prefer to start with a transverse view centered over the thyroid isthmus. This gives me a “lay of the land” in terms of the overall thyroid appearance as well as determining whether the trachea remains in the midline. By determining the shift from the midpoint of the transducer centered over the trachea to the sternal notch, quantitative measurement of tracheal deviation is included in the ultrasound report .

I then perform transverse imaging of one lobe with care to examine all of the central neck compartment tissue from well above to well below the limits of the thyroid parenchyma itself. This includes attention to any central neck lymph nodes. I then perform longitudinal imaging of the same region. Any thyroidal or extra thyroidal abnormalities are then assessed with color flow Doppler (Fig. 38.4).