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How Ultrasonography helps in the diagnosis of Hashimoto’s thyroiditis?

Paper topic: Ultrasonography in the diagnosis of Hashimoto’s thyroiditis

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Ultrasonography in the diagnosis of Hashimoto’s thyroiditis


Hashimoto’s thyroiditis is a type of autoimmune thyroid disease with an increasing prevalence in past decades. Its diagnosis is mostly based on ultrasonography. Ultrasonography is a useful and essential tool to make this diagnosis based on the characteristics of the disease. In the differential diagnosis of thyroid nodules, ultrasound-guided fine-needle biopsy is an effective method to distinguish Hashimoto’s thyroiditis from other thyroid disorders. One exciting and recent advance is that non-invasive ultrasound-based methods have supplemented fine-needle aspiration to diagnose Hashimoto’s thyroiditis under more complex conditions. In this review, we discuss the recent advantages of ultrasonography in the diagnosis of Hashimoto’s thyroiditis.


Hashimoto’s thyroiditis, also known as chronic lymphocytic thyroiditis, is a type of autoimmune thyroid disease, in which the thyroid gland is attacked by various antibody- and cell-mediated immune processes (1). In North America, prevalence of Hashimoto’s thyroiditis is 10%–15%, making it the most common cause of primary hypothyroidism (2), while its prevalence in Europe and Asia has been increasing in the past few decades. For instance, prevalence of Hashimoto’s thyroiditis increased from 2.3% in 1994 to 3.8% in 2001 in Scotland (3), and from 1.0% in 1998 to 3.9% in 2010 among individuals aged over 30 years in Korea (4). Hashimoto’s thyroiditis mostly occurs in women aged between 30 and 60 years, but also can occur in children (5). This disease can lead to symptomatic thyroid dysfunction as well as subclinical hypothyroidism and chronic autoimmune thyroiditis, ultimately progressing to thyroid failure (5). In diagnosis, evaluation, and management of Hashimoto’s thyroiditis, ultrasonography (or sonography) is an essential noninvasive tool to help therapists make clinical decisions (6). Studies have shown that echogenicity on ultrasonography is a reliable standard to confirm diagnosis or determine therapeutic efficacy (7-10). Color flow Doppler ultrasonography is used to examine the intrathyroidal vascular area (11), while high-resolution ultrasonography is used to measure the diameter of the brachial artery (12,13). Moreover, ultrasonography or Doppler sonography is a useful tool for distinguishing cases of Hashimoto’s thyroiditis comorbid with other disorders (14,15). Even in studies investigating the association between Hashimoto’s thyroiditis and other disorders, such as oral lichen planus, obstructive sleep apnea, and vitamin D deficiency, thyroid ultrasonography is a helpful tool for diagnosis (16-18). In addition to providing ultrasonographic thyroid changes, ultrasound-guided fine-needle biopsy is a minimally invasive method for pathologic diagnosis of Hashimoto’s thyroiditis, even in children (19). Fine-needle aspiration is a standard method to distinguish whether or not a thyroid nodule is malignant, and has a sensitivity of 54%–90% and specificity of 60%–90% for detecting malignant lesions (20). Even in difficult to diagnose cases, ultrasound-guided fine-needle biopsy is an effective tool to confirm accurate diagnosis of Hashimoto’s thyroiditis (21,22). In this review, we will discuss ultrasonography for diagnosis of Hashimoto’s thyroiditis, focusing on its ultrasonographic characteristics.


In the pathophysiology of Hashimoto’s thyroiditis, thyrocyte destruction by antibody- or immune cell–mediated cytotoxicity leads to morphologic and microscopic changes, including enlargement of the thyroid, parenchymal infiltration by inflammatory cells, fibroplastic proliferation, calcification, and vascular proliferation. These changes are the basis of the ultrasonographic characteristics of Hashimoto’s thyroiditis. Mazziotti and colleagues (23) analyzed 89 patients with Hashimoto’s thyroiditis and 40 healthy controls, and found that thyroid echogenicity evaluated by gray-scale quantitative analysis was lower in patients with the disease, and that thyroid hypoechogenicity was associated with occurrence of hypothyroidism in the patients (23). Even in cases with difficult diagnosis, hypoechogenicity was valuable for clarifying diagnosis (24). This association may be due to the pathologic basis of hypoechogenicity, wherein inflammatory cells infiltrate into the thyroid. In addition to hypoechogenicity, pseudonodules and inhomogeneous parenchyma have been observed in patients with Hashimoto’s thyroiditis (25,26), which may be related to fibroplastic proliferation (Figure 1). In recent years, a computer-aided diagnostic technique has been applied in thyroid ultrasonography. The gray-scale features and classifiers of this technique can provide objective and reproducible differentiation between Hashimoto’s thyroiditis and normal conditions with an accuracy of 80%, sensitivity of 76%, specificity of 84%, and positive predictive value of 83.3% for detection of Hashimoto’s thyroiditis (27). Hashimoto’s thyroiditis affects 1.3% of children (28,29). In children with Hashimoto’s thyroiditis, 37% demonstrate sonographic thyroid changes, while 50% with normal thyroid findings initially will develop changes within seven months (30). These sonographic changes may primarily be due to goiter (30). However, in some cases, classic sonographic findings may not develop for over four years. An exciting advantage of ultrasonography is that the resistive index in color Doppler may be more sensitive than other parameters for diagnosis of Hashimoto’s thyroiditis in children (31). In one case report of a 12-year-old girl with Hashimoto’s thyroiditis, some rare findings were observed on ultrasonography, including serial changes that went from early features of inflammation to severe features of endstage Hashimoto’s thyroiditis, which then returned to almost normal with only minimal features of inflammation, paralleling changes in thyroid function (32). In the case of a 59-year-old woman with hypothyroidism, color flow Doppler sonography detected a solid hypervascularized nodule, assisting in diagnosis of Hashimoto’s thyroiditis (33), and reflecting the significant role of color flow Doppler in diagnosis of this disease. Doppler measurements can enhance sonography by assessing the frequency shift of blood flow (34). On color Doppler ultrasonography of the thyroid, vascularity types (including hypovascularity), marked internal flow, and focal thyroid inferno may be observed in Hashimoto’s thyroiditis, among which “focal thyroid inferno” may be an indicator of focal Hashimoto’s thyroiditis with a diagnostic sensitivity and specificity of 7.7.% and 100%, respectively (35). Later, Fu and colleagues (36) confirmed this finding that “focal inferno” may be a characteristic of the disease on color Doppler ultrasonography. Recently, a study including 144 patients with Hashimoto’s thyroiditis found heterogeneous echotexture with increased vascularity in the majority of patients (37), suggesting a novel characteristic on ultrasonography. Wu and colleagues (38) confirmed this finding and proposed that an ovoid-to-round shape, well-defined boundary, and hypervascularity may be associated with focal Hashimoto’s thyroiditis. Increased blood flow. in the hypoechoic lesions also can be used to monitor recurrence of Hashimoto’s thyroiditis (39). However, Hashimoto’s thyroiditis cannot be detected based on blood flow in all patients with the disease. In some cases, a hypoechoic area may appear, but without blood flow in that area (40). Thus, diagnosis of Hashimoto’s thyroiditis cannot be excluded when blood flow is not detected on color Doppler. Multiple sonographic characteristics should be considered in atypical cases. In cases with difficult nodular diagnosis, ultrasound-guided fine-needle biopsy is an effective minimally invasive method to elucidate the nature of the lesion and determine the therapeutic strategy (41,42). Even in a new variant of the disease, immunoglobulin G4–related Hashimoto’s thyroiditis, ultrasoundguided fine-needle biopsy can provide evidence for diagnosis (43).


As an essential tool for diagnosis of Hashimoto’s thyroiditis, ultrasonography plays a crucial role in differentiating between Hashimoto’s thyroiditis and other thyroid disorders. For example, when distinguishing Hashimoto’s thyroiditis from Graves’ disease, which have a similar thyroid echographic pattern on ultrasonography, color flow Doppler sonography could provide valuable evidence of diffusely increased thyroid blood flow (44). In addition to benign diseases, differential diagnosis between Hashimoto’s thyroiditis and thyroid cancer is more common in patients with thyroid nodules. Therefore, ultrasonography combined with color flow Doppler sonography is effective for studying differential diagnoses (45). When ultrasonography cannot distinguish Hashimoto’s thyroiditis from other thyroid diseases, ultrasound-guided fine-needle aspiration cytology can be helpful (46). In some cases of Hashimoto’s thyroiditis and other diseases involving the neck, such as neurofibromatosis type 1, mucosa-associated lymphoid tissue lymphoma, or Bethesda grade III nodules, ultrasound-guided fine-needle aspiration cytology could help provide evidence of Hashimoto’s thyroiditis for accurate diagnosis (47-49).


When Hashimoto’s thyroiditis coexists with thyroid nodules, diagnosis may be complex and difficult. Even though some cases can be diagnosed by using noninvasive ultrasonography (50), ultrasound-guided fine-needle biopsy has been reported to be a valuable method for accurate diagnosis of Hashimoto’s thyroiditis coexisting with other thyroid disorders in a large series of patients (51,52) and in some cases with difficult diagnosis (53-55). Although fine-needle aspiration biopsy plays a crucial role in diagnosis of thyroid nodules, recent studies have focused on noninvasive ultrasoundbased methods for diagnosis of Hashimoto’s thyroiditis under complex conditions to supplement fine-needle aspiration. Acoustic radiation force impulse (ARFI) is a new modality to evaluate tissue stiffness quantitatively. Liu and colleagues (56) found that ARFI elastography is an effective method to distinguish between benign and malignant thyroid nodules in patients with Hashimoto’s thyroiditis. Virtual touch tissue quantification (VTQ) involves quantitative implementation of ARFI, and provides objective numerical evaluation of tissue stiffness in order to evaluate thyroid nodules (57,58). In a preliminary study with 118 subjects, VTQ technology was shown to be useful for differentiating between malignant and benign thyroid nodules coexisting with Hashimoto’s thyroiditis (59). This study further found that 2.75 m/s may be the best cut-off point for shear wave velocity between malignant and benign thyroid nodules. In addition, contrast-enhanced ultrasonography, which applies contrast medium to traditional medical sonography, has been found to improve diagnostic accuracy of thyroid nodules coexisting with Hashimoto’s thyroiditis (60). This noninvasive ultrasound-based method may lead to a tendency of using ultrasonography for diagnosis of thyroid disorders. As computer technology is developed, computer-aided diagnostic techniques in ultrasonography will provide additional novel methods with improved diagnostic accuracy, sensitivity, and specificity.


In conclusion, ultrasonography is an essential tool for diagnosis of Hashimoto’s thyroiditis. Color flow Doppler could further help to diagnose Hashimoto’s thyroiditis based on “focal thyroid inferno.” However, when Hashimoto’s thyroiditis coexists with other thyroid disorders or is difficult to distinguish from other diseases, noninvasive ultrasound-based methods may be insufficient. At this time, ultrasound-guided fine-needle biopsy is an effective choice. Although there is no doubt that ultrasound-guided fine-needle aspiration cytology plays a crucial role in diagnosis of Hashimoto’s thyroiditis, noninvasive methods may be preferred in the future. Recent studies have found that certain noninvasive ultrasound-based methods, which supplement fineneedle aspiration, are able to improve diagnostic accuracy of Hashimoto’s thyroiditis. New insights into development of noninvasive ultrasound-based methods, will be aided by novel computer technology to further improve diagnosis of Hashimoto’s thyroiditis and other thyroid disorders.


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Abbreviations: ARFI: Acoustic radiation force impulse; VTQ: virtual touch tissue quantification

Key Words: Ultrasonography, Hashimoto’s Thyroiditis, Diagnosis, Review


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