Pattern Recognition: Diffuse Thyroid Disease

  • Mark A. LupoEmail author


Diffuse enlargement of the thyroid gland is a common finding during both physical examination and during ultrasound evaluation. While chronic lymphocytic thyroiditis (CLT), Hashimoto’s thyroiditis, is the most common cause of goiter and hypothyroidism in countries with adequate iodine intake, thyroiditis refers to a diverse group of conditions caused by thyroid inflammation. The sonographic hallmark of thyroid autoimmunity is diffuse hypoechogenicity and heterogeneity, with multiple variants having been described. Understanding the various features of thyroiditis provides valuable clinical insight into the disease process. Moreover, pattern recognition of the various sonographic presentations of autoimmune diffuse thyroid disease is essential in determining if a focal abnormality represents a true nodule which may require fine-needle aspiration biopsy or is simply part of the inflammatory process. Doppler interrogation of the thyroid in a patient with thyrotoxicosis can often differentiate Graves’ disease from silent or subacute thyroiditis. Reactive appearing lymph nodes in the paratracheal and adjacent lateral neck regions are common in thyroiditis. Real-time imaging or the use of cine-clips is superior to static imaging in detecting diffuse thyroid disease and ideally is performed by the clinician caring for these patients. As such, this chapter includes electronic supplementary material (ESM).


Thyroiditis Diffuse enlargement Ultrasound Hashimoto’s Graves’ Heterogeneity (heterogeneous) Pseudonodule Fibrosis Lymph node Hypoechoic Doppler Thyrotoxicosis Drug-induced thyroiditis Silent thyroiditis Heterogeneity Variability Hypoechogenicity 

Supplementary material

Video 16.1

Early Hashimoto’s (MP4 6952 kb)

Video 16.2

Pseudomicronodule’s (MP4 7181 kb)

Video 16.3

Profoundly hypoechoic (MP4 8659 kb)

Video 16.4

Developing fibrosis—LONG (MP4 8397 kb)

Video 16.5

Developing fibrosis—TRV (MP4 12,553 kb)

Video 16.6

Tubercle of Zuckerkandl (MP4 17,834 kb)

Video 16.7

Hyperechoic (MP4 17,692 kb)

Video 16.8

Fibrosis with speckling—LONG (MP4 9175 kb)

Video 16.9

Fibrosis with speckling—TRV (MP4 5830 kb)

Video 16.10

Paratracheal nodes (MP4 13,362 kb)

Video 16.11

Ectopic Hashimoto (MP4 14,885 kb)

Video 16.12

Pyrimidal lobe in Hashimoto (MP4 12,465 kb)


  1. 1.
    Kim DW. A comparative study of real-time and static ultrasonography diagnoses for the incidental detection of diffuse thyroid disease. Endocr Pract. 2015;21(8):910–6.CrossRefGoogle Scholar
  2. 2.
    Pearce E, Farwell A, Braverman L. Current concepts: thyroiditis. N Engl J Med. 2003;384(26):2646–55.CrossRefGoogle Scholar
  3. 3.
    Pedersen OM, Aardal NP, Larssen TB, et al. The value of ultrasonography in predicting autoimmune thyroid disease. Thyroid. 2000;10(3):251–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Raber W, Gessi A, et al. Thyroid ultrasound versus antithyroid peroxidase antibody determination: a cohort study of four hundred fifty-one subjects. Thyroid. 2002;12(8):725–31.CrossRefPubMedGoogle Scholar
  5. 5.
    Rago T, Chiovato L, Grasso L, et al. Thyroid ultrasonography as a tool for detecting thyroid autoimmune diseases and predicting thyroid dysfunction in apparently healthy subjects. J Endocrinol Invest. 2001;24:763–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Rotondi M, Cappelli C, Leporati P, et al. A hypoechoic pattern of the thyroid at ultrasound does not indicate autoimmune thyroid diseases in patients with morbid obesity. Eur J Endocrinol. 2010;163(1):105–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Loy M, Cianchetti ME, Cardia F, et al. Correlation of computerized gray-scale sonographic findings with thyroid function and thyroid autoimmune activity in patients with Hashimoto’s thyroiditis. J Clin Ultrasound. 2004;32:136–40.CrossRefPubMedGoogle Scholar
  8. 8.
    Livolsi VA. The pathology of autoimmune thyroid disease: a review. Thyroid. 1994;4(3):333–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Williams A, Bieler D, Wieler H, et al. Correlation between sonography and antibody activity in patients with Hashimoto thyroiditis. J Ultrasound Med. 2013;32(11):1979–86.CrossRefGoogle Scholar
  10. 10.
    Lupo M, Levine R. Ultrasound of diffuse thyroid enlargement: thyroiditis. In: Baskin J, Duick D, Levine A, editors. Thyroid ultrasound and ultrasound guided FNA. 3rd ed. New York, NY: Springer; 2013.Google Scholar
  11. 11.
    Kim HS, Han BK, Shin JH, et al. Papillary thyroid carcinoma of a diffuse sclerosing variant: ultrasonographic monitoring from a normal thyroid gland to mass formation. Korean J Radiol. 2010;11(5):579–82.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Beland MD, Kwon L, Delellis RA, Cronin JJ, Grant EG. Nonshadowing echogenic foci in thyroid nodules. Are certain appearances enough to avoid thyroid biopsy? J Ultrasound Med. 2011;30:753–60.CrossRefPubMedGoogle Scholar
  13. 13.
    Gul K, Dirikoc A, Kiyak G, et al. The association between thyroid carcinoma and Hashimoto’s thyroiditis: the ultrasonographic and histopathologic characteristics of malignant nodules. Thyroid. 2010;20:873–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Fiore E, Rago T, Latrofa F, et al. Hashimoto’s thyroiditis is associated with papillary thyroid carcinoma: role of TSH and of treatment with L-thyroxine. Endocr Relat Cancer. 2011;18(4):429–37.CrossRefPubMedGoogle Scholar
  15. 15.
    Anil C, Goksel S, Gursoy A. Hashimoto’s thyroiditis is not associated with increased risk of thyroid cancer in patients with thyroid nodules: a single-center prospective study. Thyroid. 2010;20(6):601–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Anderson L, Middleton W, et al. Hashimoto thyroiditis: Part 1, Sonographic analysis of the nodular form of hashimoto thyroiditis. AJR Am J Roentgenol. 2010;195:208–15.CrossRefPubMedGoogle Scholar
  17. 17.
    Anderson L, Middleton W, et al. Hashimoto thyroiditis: Part 2. Sonographic analysis of benign and malignant nodules in patients with diffuse hashimoto thyroiditis. AJR Am J Roentgenol. 2010;195:216–22.CrossRefPubMedGoogle Scholar
  18. 18.
    Ohmori N, Miyakawa M, Ohmori K, et al. Ultrasonographic findings of papillary thyroid carcinoma with Hashimoto’s thyroiditis. Intern Med. 2007;46(9):547–50.CrossRefPubMedGoogle Scholar
  19. 19.
    Durfee SM, Benson CB, Arthaud DM, et al. Sonographic appearance of thyroid cancer in patients with Hashimoto thyroiditis. J Ultrasound Med. 2015;34(4):697–704.CrossRefPubMedGoogle Scholar
  20. 20.
    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;193:207–13.CrossRefPubMedGoogle Scholar
  21. 21.
    Brancato D, Citarrella R, Richiusa P, et al. Neck lymph nodes in chronic autoimmune thyroiditis: the sonographic pattern. Thyroid. 2013;23(2):173–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Ralls PW, Mayekawa DS, Lee KP, et al. Color-flow Doppler sonography in Graves disease: “thyroid inferno”. AJR Am J Roentgenol. 1988;150(4):781–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Erdogan MF, Anil C, Cesur M, et al. Color flow Doppler sonography for the etiologic diagnosis of hyperthyroidism. Thyroid. 2007;17:223–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Kurita S, Sakurai M, Kita Y, et al. Measurement of thyroid blood flow area is useful for diagnosing the cause of Thyrotoxicosis. Thyroid. 2005;15:1249–52.CrossRefPubMedGoogle Scholar
  25. 25.
    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.CrossRefGoogle Scholar
  26. 26.
    Bogazzi F, Vitti P. Could improved ultrasound and power Doppler replace thyroidal radioiodine uptake to assess thyroid disease? Nat Rev Endocrinol. 2008;4:70–1.Google Scholar
  27. 27.
    Bahn RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocr Pract. 2011;17(3):456–520.CrossRefPubMedGoogle Scholar
  28. 28.
    Cappelli C, Pirola I, de Martino E, et al. The role of imaging in Graves’ disease: a cost-effectiveness analysis. Eur J Radiol. 2008;65:99–103.CrossRefPubMedGoogle Scholar
  29. 29.
    Sipos JA, Kahaly GJ. Imaging of thyrotoxicosis. Am J Med. 2012;125(9):S1–2.CrossRefPubMedGoogle Scholar
  30. 30.
    Alzahrani AS, Ceresini G, Aldasouqi SA. Role of ultrasonography in the differential diagnosis of thyrotoxicosis: a noninvasive, cost-effective, and widely available but underutilized diagnostic tool. Endocr Pract. 2012;18(4):567–78.CrossRefPubMedGoogle Scholar
  31. 31.
    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(6):823–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Saleh A, Fürst G, Feldkamp J, et al. Estimation of antithyroid drug dose in Graves’ disease: value of quantification of thyroid blood flow with color duplex sonography. Ultrasound Med Biol. 2001;27(8):1137–41.CrossRefPubMedGoogle Scholar
  33. 33.
    Baldini M, Orsatti A, Bonfanti MT, et al. Relationship between the sonographic appearance of the thyroid and the clinical course and autoimmune activity of Graves’ disease. J Clin Ultrasound. 2005;33(8):381–5.CrossRefPubMedGoogle Scholar
  34. 34.
    Zingrillo M, D’Aloiso L, Ghiggi MR, et al. Thyroid hypoechogenicity after methimazole withdrawal in Graves’ disease: a useful index for predicting recurrence? Clin Endocrinol (Oxf). 1996;45(2):201–6.CrossRefGoogle Scholar
  35. 35.
    Premawardhana LD, Parkes AB, Ammari F, et al. Postpartum thyroiditis and long-term thyroid status: prognostic influence of TPO antibody and US echogenicity. J Clin Endocrinol Metab. 2000;85:71–5.CrossRefPubMedGoogle Scholar
  36. 36.
    Yeh H, Futterweit W, Gilbert P. Micronodulation: ultrasonographic sign of Hashimoto thyroiditis. J Ultrasound Med. 1996;15:813–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Thyroid & Endocrine Center of FloridaFlorida State University, College of MedicineSarasotaUSA

Personalised recommendations