ESR Essentials: thyroid imaging-practice recommendations by the European Society of Head and Neck Radiology

Thyroid nodules are frequently encountered at imaging, yet most are benign and do not require intervention. The clinical challenge lies in distinguishing nodules that warrant further investigation from those that do not, to avoid unnecessary biopsies, anxiety, and overtreatment. Ultrasound (US) is the primary imaging modality for thyroid nodule evaluation, supported by structured risk stratification systems such as ACR TI-RADS and EU-TIRADS, which incorporate specific sonographic features and size thresholds to guide clinical decision-making. Nodules without high-risk features can be safely monitored or ignored, especially in asymptomatic patients. Conversely, suspicious characteristics (e.g. irregular margins, microcalcifications, or marked hypoechogenicity) should prompt further assessment, including fine-needle aspiration (FNA). Diffuse thyroid disorders, including Hashimoto's thyroiditis and Graves' disease, are best assessed using US and thyroid function tests. In thyroid cancer, a multidisciplinary team approach involving radiologists, endocrinologists, pathologists, and nuclear medicine specialists is essential for optimal patient care. To implement these recommendations, radiologists should adopt standardised US reporting systems, apply evidence-based criteria for further workup, and collaborate closely with referring clinicians. This approach ensures accurate diagnosis, reduces unnecessary procedures, and aligns radiological practice with current guidelines to support high-value, patient-centred care. KEY POINTS: Ultrasound (US) is the gold standard imaging modality for evaluating thyroid pathology. Implementation of the EU-TIRADS and ACR-TIRADS constitutes a critical part of the work-up of thyroid nodules and is essential for their effective management. Interdisciplinary discussion with all specialists concerned is the most effective way of ensuring that the best possible management strategy is implemented in thyroid cancers.