HFHT's Practising Wisely Newsletter
For the whole healthcare team.
Issue 46: A Pain in the Neck...
January 9, 2018
Image courtesy of healthfixit.com/odynophagia
The Canadian Society of Otolaryngology - Head & Neck Surgery and the Canadian Association of Head and Neck Surgical Oncologists weigh in on how to avoid over-investigation of head and neck conditions. Of particular interest to us in primary care is recommendation #3:

"Don't order neck ultrasound to investigate odynophagia (discomfort or pain with swallowing) or globus sensation."

Odynophagia and globus sensation are common symptoms and the differential diagnosis can be extensive, including inflammatory, infectious, neoplastic, autoimmune and traumatic causes.
Odynophagia and globus sensation are infrequently due to an underlying neck mass, and if so, the underlying lesion is usually quite apparent on physical examination. Neck or thyroid ultrasonography ordered to investigate patients with odynophagia and globus sensation are more likely to detect other entities such as benign thyroid nodules, rather than confirming a diagnosis that explains the patient’s symptoms and can lead to a cascade of other unnecessary tests that can be harmful to patients.  Unfortunately, using tests to exclude conditions can sometimes identify other diseases such as thyroid nodules, leading to further testing such as a FNA or repeat ultrasounds and, in some cases, treatment in the form of a thyroidectomy that may be unnecessary or harmful to patients.
Increasing use of imaging neck lumps with ultrasound over the past two decades has led to a large increase in the diagnosis of thyroid cancer without an increase in mortality, likely due to growing detection of indolent forms of thyroid cancer. This has fuelled unnecessary thyroidectomies. A population-based temporal trend study published in  PLoS ONE substantiates this. Check out our Quick Links section to review the study.

In summary, avoid the temptation to order an ultrasound in these situations, lest you open up another proverbial can of worms!

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