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

1. 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

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
 FNAC and core needle biopsy
 Percutaneous treatment

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

5. Homogenous 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

7. Development from base of
tongue at the level of
foramen caecum.
Continues as thyroglossal
duct.
TGD disappears in 5-6th 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
I123
MC: above hyoid bone b/w foramen caecum
and epiglottis in midline

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

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

12. 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

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

15.  Peripheral "egg shell"
calcification surrounding
the nodule

16.  Follicular adenoma
 Well-marginated
homogeneous
hypoechogenic nodule
 Surrounded by a
hypoechogenic halo

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

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

21.  End stage of Hashimotos
thyroiditis
 hyperechogenic atrophic
gland

22.  Graves disease
 Hyperthyroidism-MCC
 Diffusely enlarged,
homogeneously
hypoechoic gland with
extremely increased
vascularity
 Thyroid inferno

23.  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

24.  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.

25.  Primary and secondary
 Primary :
Solitary parathyroid adenoma – 85%
Multiple gland adenoma or hyperplasia – 15%
Carcinoma - 1%

26.  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 • Hypervascular, posterior to the thyroid
gland
• a linear interface between the adenoma
and the thyroid gland

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

28.  Composed of lymphoid
follicles located in the
outer cortex and lymphatic
channels, blood vessels and
connective tissue, in the
inner medulla

29.  Normal Lymph nodes
 oval-shaped structure
 long/short axis ratio 1.5-2
 hypoechogenic cortex
 echogenic hilum
 central vascularity

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

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

32. Mandible
Carotid bifurcation
Omohyoid

33.  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

34.  Parotid gland
 oval, medium echogenic,
well delimitated structures

35.  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

36.  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

37.  Submandibular gland
A
P
L
M
1-sup sub
2- deep sub
3- mylohyoid
4- duct
5- facial v
6- digastic

38.  Intraductal stone.
 echogenic structure
casting an acoustic
shadowing associated with
an enlarged duct is seen in
the submandibular salivary
gland.

39.  Parotid pleomorphic
adenoma.
 A large, homogeneous
hypoechoic mass is seen in
the parotid gland.

40.  Parotid Warthin's
tumour
 A large, heterogeneous
mass is seen in the parotid
gland