Original Articles

Scanning the Post-Thyroidectomy

Neck: Appearance and Technique

Journal of Diagnostic Medical Sonography

26(5) 215223
The Author(s) 2010
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/8756479310378892
http://jdm.sagepub.com

Teresa Bieker, MBA, RT(R), RDMS, RDCS, RVT1

Abstract
Thyroid cancer is the most common type of endocrine cancer. In 2009, there were approximately 37,200 cases newly
diagnosed. Sonography is becoming the modality of choice to evaluate the neck preoperatively and postoperatively.
Accurate scanning and evaluation is essential for proper diagnosis, surgical approach, and staging.
Keywords
sonography, thyroidectomy, thyroid cancer, lymph node

Thyroid cancer is the most common endocrine cancer but

represents only 1% of all cancers. In 2009, there were
approximately 37,200 new cases, with 27,200 of those
occurring in women and 10,000 occurring in men. Two
thirds of the patients diagnosed are between the ages of
20 and 55 years, with a median age of 45 years. Between
1975 and 2001, there has been a 52% increase in reported
cases of thyroid cancer.1,2 This is in part due to incidental
findings on imaging studies, including sonography.
There are several types of thyroid cancer, including
papillary, follicular, medullary, and anaplastic. Papillary and
follicular types are classified as well-differentiated thyroid
cancers, which arise from thyroid follicular cells. They are
the most common types, accounting for approximately
80% to 90% of all thyroid cancers. Medullary and anaplastic are considered poorly differentiated thyroid cancers
and account for 5% to 10% and 1% to 2%, respectively.2,3
Radiation exposure is a known risk factor for thyroid cancer. Other causes include occupational risks, diet, lifestyle,
parity, and family history.3

Treatment Plans
Thyroid cancer is treatable with 10-year survival rates of
98% (papillary), 92% (follicular), 80% (medullary), and
13% for the fast-growing anaplastic thyroid cancer.3,4
Most patients with differentiated thyroid cancer are considered low risk. Factors that may affect outcome include
age, distant metastasis, local invasiveness, cervical lymph
node metastasis, tumor size, multifocality, and tumor subtype.46 For example, older patients with distal metastasis
have an increased risk for mortality. Also, local lymph
node metastasis places the patient at an increased risk for

distal metastasis.6 Early detection of differentiated thyroid

cancer and metastases leads to more successful treatments
and outcome.7
There have been many advances in the diagnosis and
treatment of differentiated thyroid cancer.8 However, even
with an excellent survival rate, the recurrence rate of differentiated thyroid cancer is 9% to 30%, with the majority
of recurrences presenting within the first decade following
diagnosis. Most recurrences present locoregionally, within
the thyroid bed or in the cervical lymph nodes.3,6,911 Also,
the majority of differentiated thyroid cancer metastases
affect the ipsilateral neck and can be multiple. Twenty
percent to 50% of patients will have regional lymph node
metastasis at the time of diagnosis.4 Approximately 60%
to 75% of recurrences will be in the cervical lymph nodes
(zones III and IV), whereas 20% will occur within the
thyroid bed (zone VI). Zone II and V nodes are less commonly affected. Only 5% of recurrences will affect the
trachea or muscle. Metastasis to the lymph nodes generally does not affect survival rates; however, metastasis to
the trachea or muscle decreases survival rates.4,10,12,13
For patients diagnosed with thyroid cancer, total or
near-total thyroidectomy is the standard treatment.6,8,14 If
abnormal lateral cervical lymph nodes are present, a neck
dissection is also performed.4 Following thyroidectomy,
patients are closely monitored for recurrence within the
thyroid bed and cervical nodes as well as distal metastasis.
1

Department of Radiology, University of Colorado, Aurora, CO, USA

Corresponding Author:
Teresa Bieker, MBA, RT(R), RDMS, RDCS, RVT, Department of
Radiology, University of Colorado, Box F720, Aurora, CO 80045, USA
Email: tbieker@msn.com

216
A postoperative evaluation includes physical palpation of
the neck by an endocrinologist or surgeon, neck sonogram,
and laboratory evaluation of tumor markers, including
serum thyroglobulin (Tg) and thyroglobulin antibodies.11
Depending on the extent of the disease, radioactive iodine
ablation therapy, iodine 131 whole-body scanning, chest
radiography, computed tomography (CT) or magnetic
resonance imaging (MRI) of the neck and chest, and/or
positron emission tomography (PET) imaging may be
performed.4,5,9,11,12,14,15
In the past, iodine scanning was used to detect metastasis within the lateral neck. However, it has limited sensitivity, especially within the lateral neck.12,15 Neck sonography
and laboratory evaluation are recommended every 6 to 12
months to evaluate the thyroid bed as well as the lateral
neck for 3 to 5 years following surgery.4,5,8,11

Lab Work
After a total or near-total thyroidectomy, Tg plays a critical role in the evaluation of thyroid cancer.16 Tg is a specific protein that is secreted from thyroid tissue.9,16 The
sensitivity and specificity of Tg are high in detecting thyroid cancer when followed by thyroidectomy and iodine
ablation therapy.8 In patients free from disease, the serum
Tg levels should be undetectable (<1 ng/mL). If the serum
Tg increases, it is likely caused by recurrent tumor in the
thyroid bed, within the neck, cervical lymph nodes, or
elsewhere in the body.16 An elevated Tg indicates the presence of recurrent tumor but not the specific location.12
Tg levels may be altered by antithyroglobulin antibodies. Tg antibodies are present in approximately 20% to
25% of thyroid cancer patients. If Tg antibodies are positive, the serum Tg levels will be falsely decreased.3,8 If
patients are free of disease, the Tg antibodies will typically decrease over several years. When disease is present,
Tg antibodies may increase.3 Dependent on the patients
status and thyroid cancer cell type, the serum Tg and Tg
antibodies are typically measured every 6 to 12 months.8
Even though Tg is an important marker, up to 20% of
thyroid cancer recurrences will not be detected by Tg
alone.12 This confirms the importance of using a combination of clinical, imaging, and laboratory information.
In addition, long-term management after thyroidectomy also includes suppression of thyroid-stimulating
hormone (TSH).9

Benefit of Sonography
Sonography is becoming the modality of choice for
evaluating, screening, and managing the pre- and postsurgical neck.4,6,13 The American Thyroid Association
recommends sonography to evaluate for lymph node
involvement following a thyroidectomy.6 Not only is

Journal of Diagnostic Medical Sonography 26(5)

sonography sensitive in detecting lymph nodes, but it is
more cost-effective, quicker, noninvasive, and well tolerated by patients and does not use ionizing radiation.7,15
Sonography is, however, operator dependent, and a thorough understanding of the neck anatomy and sonography
principles is needed. Accurate preoperative neck sonography is important for appropriate staging as well as surgical management.6,8,10
Because the majority of thyroid cancer recurrences are
within the anterior and lateral cervical neck, sonography
is beneficial in accessing and evaluating these superficial
areas.9 Sonography is also highly sensitive for determining benign versus malignant lymph nodes in patients with
differentiated thyroid cancer.10 Sonography can detect
recurrent disease as small as 2 to 3 mm; therefore, abnormal lymph nodes can be detected sonographically even
before they become palpable and visualized with other
imaging modalities or before laboratory values become
abnormal.7,8,10,17,18 For this reason, it has been shown that
neck sonography is superior to clinical examination.4,17
Even though sonography cannot diagnose benign versus
malignant lesion and lymph nodes, it can assist in identifying more suspicious lesions that may require biopsy.7
Sonography is also used for guidance during fineneedle aspiration (FNA) of suspicious lesions or lymph
nodes. With sonography, lesions as small as 5 mm can
be sampled. Intraoperative guidance with sonography
can also be used to more accurately localize recurrent
disease in an attempt to limit a more invasive surgical
approach.9,12,13
Even though neck sonography is beneficial, it also has
drawbacks, including operator dependency, subjectivity,
and limited evaluation of deep neck structures.13

Normal Lymph Node Anatomy

There are approximately 800 lymph nodes in the body,
and 300 of those are located within the neck.17,19 Normal
lymph nodes are composed of a cortex and a medulla,
covered by a fibrous capsule. The cortex contains lymphocytes that are tightly packed together forming spherical
lymphoid follicles, whereas the medulla is made of trabeculae and medullary cords and sinuses. Multiple medullary
sinuses form the echogenic hilus of the normal lymph
node. Each lymph node contains a main artery that enters
at the hilus. Once in the node, the artery branches into
multiple arterioles. Blood is then drained from the node
through the venous system.17,19

Sonographic Appearance
of Normal Nodes
Normal cervical lymph nodes are commonly seen by
sonography. It is not unusual to identify at least five to six

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Bieker

Figure 1. Normal oval-shaped lymph node with an echogenic

hilum located in zone III.

Figure 3. (A, B) Reactive lymph nodes within zone II in two

different patients. It is not unusual to see larger lymph nodes
near the submandibular gland.

Figure 2. Jugular lymph nodes are commonly located in

chains. Each lymph node should be evaluated for normal
characteristics. These three normal lymph nodes with
echogenic hilum are located within zone IV.

Figure 4. Normal lymph node within zone VI. Note the

hypoechoic cortex and echogenic hilum.

normal lymph nodes during routine screening of the

neck.18,19 The number of normal lymph nodes visualized
increases with age.18 Benign cervical lymph nodes are
sonographically characterized by their location, shape,
size, echogenicity, vascular pattern, and presence of an
echogenic hilum.
Benign cervical lymph nodes are typically located in
the submandibular (zone I), parotid (zone II), upper cervical (zone II), and posterior triangle (zone V) regions.17,18
Normal cervical lymph nodes are typically oblong,
oval, cigar, or kidney bean shaped (Figures 1 and 2).4,19
Reported size criteria are variable; however, it has been
shown that normal nodes have a short- to long-axis ratio
of less than 0.5.1719 Also, the size of lymph nodes varies

depending on the location. For example, nodes within

the submandibular and superior zones are typically larger
than those located more inferiorly in the neck.18,19 Inflammation from the oral cavity can be the reason for increased
size or reactive nodes in the submandibular and upper neck
zones (Figure 3).18,19 In general, lymph nodes vary in size
from 3 to 25 mm.19
Sonographically, normal cervical lymph nodes typically
have a central echogenic hilus surrounded by a hypoechoic
cortex.4 The echogenic hilum, a strong acoustic reflector,
is continuous with the surrounding tissues and can often
be identified against the more hypoechoic fat and cortex
(Figure 4).17,18 The presence of an echogenic hilus is a
strong predictor of a benign node.7,1820 Approximately

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Journal of Diagnostic Medical Sonography 26(5)

Figure 5. Normal hilar flow within a cervical lymph node.

Figure 6. Chain of abnormal, rounded, hyperechoic lymph

nodes within zone III. Note the lack of an echogenic hilum.

84% to 92% of nodes with an echogenic hilum are considered benign.20 In small nodes, an echogenic hilum may
be difficult to visualize sonographically.4 Nevertheless,
in the majority of normal lymph nodes greater than 5 mm
in diameter, a echogenic hilum can be identified.18
A hilar vascular pattern or even avascularity can be
seen within normal cervical lymph nodes (Figure 5).1720
Small nodes, less than 5 mm, often appear to be avascular.17 Flow within the larger submandibular and upper
cervical lymph nodes may be increased, but peripheral
vascularity should not be seen in normal lymph nodes.19
Multiple characteristics should be visualized to confirm benignity. A sole benign criterion is not sufficient for
an accurate diagnosis.17

used in isolation because metastases can be identified in

small nodes.17,18 In addition, reactive lymph nodes tend
to be larger in size. Lymph nodes that are increasing
in size on serial sonograms should be concerning for
metastases.18
When malignant cells invade a lymph node, the hilum
becomes displaced and is no longer identified sonographically.20 Absence of the fatty hilum, therefore, is a strong
characteristic of recurrence (Figure 6).6,7,9,17,18 Approximately 96% of malignant nodes lack a fatty hilum.19
However, it should be borne in mind that small, normal
lymph nodes may not display a visible fatty hilum.17
In addition to a lack of a fatty hilum, malignant lymph
nodes typically are hypoechoic when compared with the
surrounding tissues. This is the case with medullary thyroid cancer and lymphoma. With recurrent papillary thyroid cancer, however, the lymph node is commonly
hyperechoic (Figure 6).4,17,18,20 This hyperechoic appearance is likely due to the presence of thyroglobulin within
the lymph node.17
With disruption of the hilum, vascular patterns also
change within malignant lymph nodes. Peripheral, irregular flow can be seen with color Doppler.4,6 Peripheral or
mixed (peripheral and hilar) flow has been shown to be
highly suggestive of malignancy.17,18,20 Tumor infiltration into the lymph nodes results in the change from hilar
to peripheral flow (Figure 7).17 The clinical benefit of
pulsed Doppler for determining benign versus malignant
lymph nodes is debatable and is not considered routine
protocol.17,18,20
In general, calcifications within malignant lymph nodes
are rare. However, with recurrent medullary and, in particular, papillary thyroid cancer, calcifications within the

Sonographic Appearance
of Abnormal Nodes
Similar to normal nodes, abnormal nodes are characterized by their location, shape, size, vascular pattern, and
presence of an echogenic hilus. Abnormal nodes also
have additional important characteristics, including echogenicity, calcifications, and cystic changes.
Abnormal cervical lymph nodes can be identified within
any zone of the neck; however, abnormal-appearing
lymph nodes within the upper/mid-jugular (zone III),
low jugular (zone IV), paratracheal region (zone VI),
and supraclavicular region are more likely to be thyroid
metastases than those elsewhere in the neck.7,9,14
When recurrent disease is present, the lymph node
will lose its ovoid, elliptical shape and become more
rounded.4,6,10,1720 It has been reported that malignant
nodes are larger in size; however, this criterion cannot be

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Bieker

Figure 7. (A, B) Abnormal, peripheral flow within an

abnormal lymph node in two different patients. Also note the
rounded, echogenic appearance, microcalcifications, and lack of
an echogenic hilum.
Figure 9. Multiple enlarged cystic lymph nodes extending
from zone III to zone IV. Pathology confirmed recurrent
papillary thyroid cancer.

Figure 8. Multiple examples of abnormal lymph nodes

showing microcalcifications. (A) Complex lymph node that
is recurrent papillary carcinoma by biopsy. (B) Hypoechoic
lymph node with microcalcifications that was biopsy-proven
recurrent medullary carcinoma. (C) Hyperechoic lymph
node with microcalcifications. This lymph node was recurrent
papillary carcinoma.

node may be seen sonographically (Figure 8).6,7,10,11,14,17,20

Calcifications are typically small (microcalcifications) and
peripherally located.17,18,20 Shadowing from the calcification may or may not be visualized.18
When the cervical lymph node becomes cystic, it is
highly suggestive of recurrent papillary thyroid cancer
(Figures 9 and 10).6,7,9,14,17,18 The cystic change is caused
by necrosis secondary to tumor invasion. Regardless of
size or other characteristics, when the node is cystic, is
must be considered abnormal.20 Together, microcalcifications and cystic change within a lymph node have a specificity of near 100% for recurrent disease.4,9

Figure 10. Another example of an enlarged cystic

lymph node within zone IV. Also note the multiple
microcalcifications.

Again, a sole criterion should not be used to diagnose an abnormal lymph node. These nodes are often
characterized as suspicious and can be followed with
serial sonograms or Tg levels or may be biopsied. Multiple characteristics are needed for a more accurate sonographic diagnosis (Figure 11).

Zone VI Abnormalities
After a total or near-total thyroidectomy, the paratracheal
region should be homogeneous and uniform in appearance. It is not unusual, however, to visualize small masses
within the thyroid bed. Zone VI masses can include
postoperative scarring, muscle, necrosing fat, suture granulomas, parathyroid glands, lymph nodes, remnant tissue,
and metastasis. Suture granulomas are typically hypoechoic
with a central echogenic focus. Recurrence in zone VI can
appear round or oval in shape and is hypoechoic or nearly

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Journal of Diagnostic Medical Sonography 26(5)

Figure 11. It is important to correlate sonography findings

with the patients surgical history. In this case, the focal areas
within the sternocleidomastoid muscle are autotransplanted
parathyroid glands.

Figure 13. Zone VI abnormalities. (A) Hyperechoic oval

mass within zone VI is a biopsy-proven recurrent papillary
carcinoma. (B) A more hypoechoic mass deep within zone VI
in another patient. This was also recurrent papillary carcinoma.

Figure 12. Hypoechoic oval mass within zone VI. The

differential diagnosis includes recurrent disease, parathyroid,
or abnormal lymph node.

Figure 14. Small, hypoechoic area within zone VI. The

differential diagnosis includes recurrent disease, parathyroid,
abnormal lymph node, granuloma, or scarring.

anechoic; however, benign structures may appear similar (Figures 1215).4,12,21 Masses within zone VI can be
followed with serial sonography, correlated with serum
Tg levels, and/or biopsied.

Becoming efficient at neck scanning requires experience,

as well as a thorough knowledge of neck anatomy, potential pathology, and zones (Table 1 and Figure 16).
The patient is positioned supine with the neck hyperextended. A pillow may be placed under the patients
shoulders to assist in extending the neck. Typically, a
12-MHz or higher linear array transducer is used. A lower
frequency may be necessary for thicker necks. A small
footprint 8- to 10-MHz curved-array transducer is also

Equipment and Scanning Protocol

Postsurgical neck scanning is highly operator dependent.
Careful scanning is necessary when evaluating the neck.

Bieker

Figure 15. Focal echogenic foci within zone VI that likely

represents a suture in the thyroid bed.

helpful for evaluating the supraclavicular and submandibular regions as well as the sternal notch. Gentle compression may also be useful to distinguish nodal borders,
an echogenic hilum, and microcalcifications.
System settings should be optimized for each patient,
including power output, time gain control, compound
imaging, and dynamic range. Color Doppler settings should
also be optimized. Ideal settings include medium persistence, low wall filter, and low pulsed repetition frequency (~700 Hz). Color gain should be increased
to the point of noise, then decreased until the noise
disappears.1719
In a transverse and longitudinal plane, evaluate the
submental area, zone I. Sweep side to side, scanning to
the lateral border of the right submandibular gland and
to the lateral border of the left submandibular gland.
Then scan superior from the mandible inferiorly to the
hyoid bone.
Next, the anterior cervical and paratracheal lymph
nodes of zone VI should be evaluated. In a transverse
plane, scan from the hyoid bone inferiorly to the manubrium. The thyroid bed is located in the mid to lower
portion of zone VI. With an absent thyroid, it is not unusual
to see the carotid arteries directly adjacent to the trachea. It
is helpful to scan zone VI with the patients neck hyperextended, as well as turned to the contralateral side. By
turning the patients head, artifact within zone VI can be
reduced.
With the central neck completed, the lateral neck is then
assessed to evaluate the superior, mid, and inferior jugular
chain. In a transverse plane, scan from the posteriolateral border of the submandibular gland inferiorly to the
level of the hyoid bone. Continue to sweep inferiorly in a

221
transverse plane to the medial edge of the internal jugular
vein (IJV). This completes zone IIA. For zone IIB, posterior to the IJV, scan in a transverse plane from the mandible inferiorly to the level of the hyoid bone.
Working inferiorly, continue to scan in a transverse
plane along the internal jugular vein. Zone III is from
the hyoid bone to the cricoid cartilage, whereas zone IV
extends from the cricoid cartilage inferiorly to the clavicle. Once the zone is evaluated in the transverse plane,
scan through it in a longitudinal plane. At times, depending on the patients anatomy and habitus, the zones are
evaluated a second time with a small-faced high-frequency
transducer.
Zone V is the posterior/lateral neck and should be
scanned with the patients head turned to the contralateral
side. Make a sweep in both transverse and longitudinal
planes from posterior to the patients ear to the clavicle.
Zones VA and VB are divided at the level of the cricoid
cartilage. Zone V is posterior to the sternocleidomastoid
muscle.
Finally, with a high-frequency small-faced transducer,
scan along the clavicle and into the sternal notch. Angle
inferiorly to visualize posteriorly and deep to the clavicle.
In the sternal notch, angle laterally and inferiorly to evaluate the entire region.
The entire process should be repeated for the contralateral side. Both normal and abnormal lymph nodes
should be documented. If the node appears normal, it
should be imaged, but it is not necessary to measure it.
Any abnormal lymph nodes, however, should be measured in all three planes and evaluated with color Doppler. When evaluating lymph nodes with color Doppler,
the color box should be adjusted to the size of the
node. Nodal vascular patterns are categorized into four
types:
(1) Hilar: flow branches radially from the hilum.
(2) Peripheral: flow is present along the periphery
of the node but does not arise from the hilar
vessels.
(3) Mixed: hilar and peripheral flow is present.
(4) Absence of flow despite optimal Doppler
settings17,18
Accurate labeling of the zone is needed for all lymph
nodes. This is essential for follow-up examinations as
well as operative guidance. Abnormalities in zone VI are
considered the central compartment and are included and
evaluated during a thyroidectomy. Abnormal lymph nodes
in zones II, III, IV, and V, however, are in the lateral neck
and may require a neck dissection, which is a more extensive surgery.

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Journal of Diagnostic Medical Sonography 26(5)

Table 1. Anatomical Landmarks for Each Zone of the Neck2224

Zones
IA
IB
IIA
IIB
III
IV
VA
VB
VI
VII
Supraclavicular

Landmarks
Midline; anterior to the digastric muscle and superior to the hyoid
bone.
Lateral to zone IA but medial or anterior to the submandibular gland
Anterior or medial to the interior jugular vein but lateral/posterior to
the submandibular gland; superior to the hyoid bone
Posterior to the interior jugular vein

Nodal Group
Submental
Submandibular nodes
Upper internal jugular chain; more
superiorly, the parotid nodes
Upper internal jugular chain; more
superiorly, the parotid nodes
Middle internal jugular chain

From the level of the hyoid bone inferiorly to the cricoid arch; lateral
to the common carotid artery
From the level of the cricoid arch inferiorly to the level of the clavicle; Lower internal jugular chain
lateral to the common carotid artery
Posterior to the sternocleidomastoid muscle, from the base of the
Supraclavicular fossa/posterior triangle
skull to the cricoid arch
(spinal accessory chain and transverse
cervical chain)
Posterior to the sternocleidomastoid muscle from the croicoid arch
Supraclavicular fossa/posterior triangle
to the level of the clavicle
(spinal accessory chain and transverse
cervical chain)
Anterior/medial to the common carotid arteries from the level of the Anterior cervical nodes, pre- and
hyoid to the manubrium
paratracheal
Anterior/medial to the common carotid arteries, inferior to the
Anterior, upper mediastinal nodes
sternal notch
Lateral to the common carotid artery; at or inferior to the clavicle
Supraclavicular nodes

Figure 16. Schematic drawing showing zone landmarks. Adapted from Som PM, Curtin HD, Mancuso AA. An imaging-based
classification for the cervical nodes designed as an adjunct to recent clinically based nodal classifications. Arch Otolaryngol Head
Neck Surg 1999;125:388396.

Bieker

Conclusion
With thyroid cancer on the rise, endocrinologists, surgeons, radiologists, and sonographers will be faced with
an increased number of patients. Many of these patients
will benefit from neck sonography. In the proper hands,
sonography can continue to emerge as the first modality
used for preoperative and postoperative diagnosis,
screening, and staging of thyroid cancer.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the authorship and/or publication of this article.

Funding
The author(s) received no financial support for the research
and/or authorship of this article.

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