Diagnosis in this case is subacute thyroiditis. Symptoms are more severe in acute thyroiditis with complications and acute thyroiditis is more common in children. Just take a look of acute thyroiditis. • Acute thyroiditis is rare and due to suppurative infection of the thyroid. • More common in children and often is preceded by an upper respiratory tract infection or otitis media. Etiology The thyroid gland is inherently resistant to infection due to its extensive blood and lymphatic supply, high iodide content, and fibrous capsule. Infectious Agents can Seed Thyroid 1. Via hematogenous or lymphatic route 2. Via direct spread from persistent pyriform sinus fistulae or thyroglossal duct cysts 3. As a result of penetrating trauma 4. Due to immunosuppression • Streptococcus and anaerobes account for about 70% of cases. • In children and young adults, MC cause is presence of a pyriform sinus (remnant of the fourth branchial pouch that connects the oropharynx with thyroid), such sinuses are predominantly left-sided. • Long-standing goiter and degeneration in thyroid malignancy are risk factors in elderly. Clinical Features • Thyroid pain, often referred to the throat or ears, and a small, tender goiter. • Fever, dysphagia and erythema over the thyroid. • Systemic symptoms of a febrile illness and lymphadenopathy. • Complications such as systemic sepsis, tracheal or esophageal rupture, jugular vein thrombosis, laryngeal chondritis, and perichondritis or sympathetic trunk paralysis may also occur. Diagnosis • ESR and WBC count are usually increased, but thyroid function is normal. • FNA biopsy shows infiltration by polymorphonuclear leukocytes. • Culture of the sample can identify the organism. • Persistent pyriform sinus fistula should be suspected in children with recurrent acute thyroiditis. A barium swallow demonstrates the anomalous tract with 80% sensitivity. Treatment • Parenteral antibiotics and drainage of abscesses. • Patients with pyriform sinus fistulae require complete resection of the sinus tract, including the area of the thyroid where the tract terminates, to prevent recurrence.