Usg neck

ultrasound neck basics - thyroid, parathyroid, lymph nodes, salivary glands

1. ULTRASOUND NECK PG: Nasin Usman Moderator: Dr. Priya

2. First used imaging modality Position: supine, hyperextended neck High frequency linear transducer (5-12 MHz) Transverse and longitudinal planes Introduction

3. Detection of lymphadenopathy, salivary gland and soft tissue pathologies Most sensitive imaging test for examination of thyroid gland focal lesions and diffuse abnormalities in the thyroid parenchyma Characterization of mass vascularization and for the accurate evaluation of neck vessels FNA C and core needle biopsy Percutaneous treatment Indications

4. 2 lobes – connected by isthmus Length: 4-6 cm AP/ Transverse: 1.3 -1.8 cm Isthmus: 3mm Thyroid Gland Anatomy THYROMEGALY: AP > 2 cm Isthmus > 4 mm

5. Thyroid gland anatomy H omogenous echopattern , hyperechoic compared to the neck muscles. Anechoic vessels – JV(compressible), CA (non compressible & pulsatile)

6. STA – from ECA – supply upper pole ITA – TCT – to deep part of the gland Variable thyroidea ima (3%) from BCA/Aorta Sup and middle thyroid veins into IJV Inf thyroid veins into left BCV Blood supply

7. Variations in normal anatomy Development from base of tongue at the level of foramen caecum. Continues as thyroglossal duct. TGD disappears in 5-6 th wk IUL

8. Small isoechoic mass in superior aspect of the left thyroid lobe Same echoes as surrounding gland Pyramidal lobe

9. Ectopic/ Lingual thyroid Thyroid scintigraphy I 123 MC: above hyoid bone b/w foramen caecum and epiglottis in midline Congenital Anomalies

10. Thyroglossal cyst Cystic mass with low level internal echoes Midline between isthmus and hyoid bone Congenital anomalies

11. Thyroid nodules Incidence: directly correlated with age (~Age minus 10) 10-13% of nodules: CA Focal disease MC lesion: Hyperplastic nodule Or colloid / adenomatous nodule Etiology: idiopathic/ iodine deficiency/ disorders of hormone synthesis

12. Focal disease Multinodular goitre Multiple nodules of variable echogenicity are seen scattered in an enlarged thyroid gland

13. Cystic components with septations in a benign goiterous nodule Focal disease

14. Ring down / comet tail sign from bright foci in a mixed solid and cystic colloid nodule, representing inspissated colloid Focal disease

15. Peripheral " egg shell " calcification surrounding the nodule Focal disease

16. Follicular adenoma Well- marginated homogeneous hypoechogenic nodule S urrounded by a hypoechogenic halo Focal disease

17. Papillary thyroid cancer Hypoechoic poorly marginated solid lesion. FNAC done Complex lesion, solid with internal cystic components.

18. Papillary thyroid cancer Metastatic jugular lymphadenopathy with microcalcifications and cystic changes

19. Hashimotos thyroiditis Chronic immune lymphocytic thyroiditis Hypothyroidism Increased risk for thyroid lymphoma Diffuse disease Heterogenous echotexture . Scattered tiny hypoechoic nodules. Increased vascularity. Diffusely hypoechoic heterogeous gland, with hyperechoic fibrous strands.

20. End stage of Hashimotos thyroiditis hyperechogenic atrophic gland

21. Graves disease Hyperthyroidism- MCC Diffusely enlarged, homogeneously hypoechoic gland with extremely increased vascularity Thyroid inferno Diffuse disease

22. Subacute granulomatous thyroiditis (de Quervain's thyroiditis ) Diffusely enlarged hypoechoic heterogeneous gland, with poorly defined areas of hypoechogenicity in both lobes of the thyroid gland Diffuse disease

23. Usually four , two upper , located behind the middle portion of the each thyroid lobe, and two lower, behind and just inferior to the lower poles of the thyroid gland Oval in shape 1*3*5 mm in diameter almost never seen with ultrasound unless enlarged. Parathyroid Anatomy

24. Primary and secondary Primary : S olitary parathyroid adenoma – 85% Multiple gland adenoma or hyperplasia – 15% Carcinoma - 1 % Hyperparathyroidism

25. Parathyroid adenoma Large solid hypoechoic parathyroid adenoma of the upper parathyroid gland Ectopic adenoma( 3% ): retrotracheal and retroesophageal , in the lower neck and mediastinum, in the carotid sheath and intrathyroid Hyperparathyroidism Hypervascular , posterior to the thyroid gland a linear interface between the adenoma and the thyroid gland

26. Parathyroid Adenoma in the sheath of the common carotid artery combination of sonography and scintigraphy with sestamibi Hyperparathyroidism Technetium 99-m sestamibi scintigraphy : Delayed (120') image shows persistent uptake in the PTA and show out in the thyroid gland

27. Composed of lymphoid follicles located in the outer cortex and lymphatic channels, blood vessels and connective tissue, in the inner medulla Lymph Nodes Anatomy

28. Normal Lymph nodes oval-shaped structure long/short axis ratio 1.5-2 hypoechogenic cortex echogenic hilum central vascularity Lymph Nodes Anatomy

29. Reactive LA Oval-shaped lymph node thickened homogenously hypoechogenic cortex larger than 5 mm in short diameter preserved echogenic hilum central increased vascularity Lymphadenopathy

30. Malignant LA Round-shaped enlarged, very hypoechoic heterogeneous Long-short axis ratio less than 1.5 Absent echogenic hilum Peripheral vascularity Cystic changes, microcalcifications Lymphadenopathy

31. Levels of neck nodes Mandible Carotid bifurcation Omohyoid

32. Parotid Gland smaller deep part and a larger superficial part, both of which are continuous around the posterior aspect of the ramus of the mandible via the isthmus Facial N Masseter ECA and Post fac V TS ICA IJV Mastoid SCM Ramus of Mand Duct Salivary Glands Anatomy

33. Parotid gland oval , medium echogenic, well delimitated structures Salivary Glands Anatomy

34. Submandibular Gland medial to the angle of the mandible mixed mucinous and serous gland-tendency to form calculi lower superficial lobe continuous with a smaller deep lobe above around the posterior border of the mylohyoid muscle Salivary Glands Anatomy

35. Submandibular gland Wharton ’ s duct about 5 cm long commences as a confluence of several ducts in the superficial (lower) lobe runs superiorly through the deep (upper) lobe before running forward in the floor of the mouth open at the side of the frenulum of the tongue Salivary Glands Anatomy

36. Submandibular gland Salivary Glands Anatomy A P L M 1-sup sub 2- deep sub 3- mylohyoid 4- duct 5- facial v 6- digastic

37. Intraductal stone . echogenic structure casting an acoustic shadowing associated with an enlarged duct is seen in the submandibular salivary gland. Enlarged salivary glands

38. Parotid pleomorphic adenoma. A large, homogeneous hypoechoic mass is seen in the parotid gland. Enlarged salivary glands

39. Parotid Warthin's tumour A large, heterogeneous mass is seen in the parotid gland Enlarged salivary glands