ultrasound neck

37Ultrasound of the NeckJ.A. Castelijns, Michiel W.M. van den Brekel,

Suresh K. Mukherji, and J.S. Lameris

EXAMINATION TECHNIQUE OF THE NECKULTRASOUND-GUIDED FINE-NEEDLEASPIRATION CYTOLOGY

SONOGRAPHIC ANATOMY OF THE NORMALNECKThyroid GlandParathyroid GlandSalivary GlandsThe Neck (Cervical Lymph Nodes)

ULTRASONOGRAPHY OF NECK PATHOLOGYThyroid GlandDiffuse Thyroid DiseaseFocal Thyroid DiseasePercutaneous Aspiration Under UltrasoundGuidance

Tumor Recurrence After ThyroidectomyUltrasound-Guided Sclerotherapy ofThyroid Cysts

Parathyroid GlandPrimary HyperparathyroidismImaging Indications

SALIVARY GLANDSialolithiasisTumors and Tumor-Like ConditionsPleomorphic AdenomaWarthin’s TumorMalignant Tumors

NODAL NECK DISEASENonneoplastic LymphadenitisMalignant LymphomasMetastatic Lymphadenopathy

OTHER CERVICAL SITES: CONGENITAL CYSTICLESIONS AND NONNODAL MASSES OF THENECKCystic LesionsInfectious DiseaseLipomasNeurogenic Tumors

THE ROLE OF ULTRASOUND FOREVALUATION OF INFANTS AND YOUNGCHILDREN

Although CT and MR imaging can be used for theevaluation of a variety of head and neck disorders,ultrasound may be the initial modality for evaluatingsuperficial structures. Ultrasound may also be preferred forguiding needle aspirations (punctures) of all types of lesionsin the neck. Ultrasound, and if necessary ultrasound-guidedfine-needle aspiration cytology, is also useful for evaluatingthyroid and parathyroid gland lesions, for evaluatingcervical nodes, and for the diagnostic evaluation of salivarygland tumors. The noninvasiveness of ultrasound makes thisan ideal modality for evaluating neck masses in infants andchildren. This chapter will review the potential of ultrasoundand ultrasound-guided fine-needle aspiration cytology forevaluating a variety of disorders involving the extracranialhead and neck.

EXAMINATION TECHNIQUE OF THE NECK

The patient is examined in a supine position with the neckmildly hyperextended. The neck should be examined with ahigh-frequency linear array transducer ranging from 7.5 to10 MHz. Blood flow can be studied using Duplexsonography, in which gray scale 2D sonography iscombined with pulsed Doppler. With color Doppler imaging(CDI), the pulsed Doppler information is encoded for flowdirection and (mean) flow velocity and displayed in the 2Dimage. The relative direction of flow (toward or away fromthe transducer) is shown by the use of a suitable color (e.g.,red or blue). Power Doppler shows the intensity of flow,which is proportional to the square of the amplitude of theDoppler signal. It is usually presented in a unidirectional

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form (Fig. 37-1). CDI is generally used to examineintravascular flow, while the more sensitive power Doppleris used to detect parenchymal flow. Flow patterns (velocityin time) during the cardiac cycle are studied with duplexscanning. Many indices of waveform analysis have beendescribed, but only the resistance index (RI = (maximumvelocity − minimum velocity) / maximum velocity) is usedto characterize parenchymal flow. The RI is particularlysensitive to changes in downstream flow resistance. Neovas-cularization, as seen in many tumors, causes a decrease inthe RI compared to normal tissue. Depending on theindication (swelling of the neck, suspicion of a thyroid orparathyroid lesion, etc.), particular attention should be givento certain regions of the neck. Level I should be evaluated inthe coronal plane. Generally, levels II to V should beevaluated longitudinally (craniocaudally) and in the axialplane. The thyroid gland should be imaged entirely in boththe transverse and longitudinal planes. Potential enlarge-ment of the parathyroid gland should be evaluated,particularly if there are indications of adenoma, hyperplasia,and so on. The parotid gland should be examined in the axialplane. Sometimes it may be difficult to assess the origin of alesion (intra- or extraparotid), and imaging in otherdirections should be performed. Levels I to V of both sidesof the neck should be examined for the presence of enlargednodes, particularly in patients known to have head and neckcancer or parotid lesions or when a suspicious thyroidnodule is encountered. All nodes that are visible onultrasound are measured in the axial plane. We prefer tomeasure the minimal axial diameter, since we consider thisto be the most accurate size criterion in differentiatingbetween benign and malignant disease.

ULTRASOUND-GUIDED FINE-NEEDLEASPIRATION CYTOLOGY

Fine-needle aspiration cytology (FNAC) has a major rolein the diagnosis of palpable or nonpalpable thyroid lesionsbecause of the absence of reliable clinical or ultrasono-graphic criteria for differentiation between benign andmalignant disease. The procedure is safe and easily

performed in an outpatient setting (Fig. 37-2). Ultrasound-guided FNAC can provide a cytologic diagnosis in a largepercentage of lesions. We prefer ‘‘freehand’’ FNAC using asyringe holder (Cameco, Tayby, Sweden). A 22-gauge(25-mm) noncutting needle equipped with 10- or 20-mlaspiration syringes should be used. A longer needle shouldbe used for deeper lesions. After antiseptic preparation, theneedle should be advanced 0.5 to 1 cm from the middle ofthe long axis of the transducer. After visualization of theneedle tip in the lesion, syringe suction should be appliedand the needle moved gently but rapidly through the mass.An ideal specimen for cytologic analysis consists of 1 or 2drops of orange-red fluid. Cutting needles generally yieldvery cellular specimens but are more difficult to insert thanthe sharper noncutting needle.1 The smears are fixed using70% ethanol, stained with Papanicolaou stain, and air-driedand stained with May-Grunwald-Giemsa solution. Theneedle and syringe are washed with Carbowax to obtainadditional smears. Repeated ultrasound-guided FNAC,possibly with the use of on-site cytopathology review, mayreduce the number of nondiagnostic aspirates. Spring-activated automated biopsy guns may also allow moreaccurate histologic diagnosis without a significant increasein the complication rate.2

If the aspirate obtained by ultrasound-guided FNACcontains blood, a nonaspiration technique may be used inwhich the 22-gauge needle is inserted without suction.Capillary action causes cells to move into the needle as it ismoved in a back-and-forth excursion within the mass.1 Thistechnique may be especially useful when aspirating thyroidnodules.

SONOGRAPHIC ANATOMY OF THENORMAL NECK

This section describes the normal ultrasonographicanatomy of the thyroid gland, the parathyroid glands, thesalivary glands, and the cervical nodes. The axial anatomy

FIGURE 37-1 Power Doppler ultrasound shows hilar flow (arrows)inside a small normal lymph node, which is seen with low signal intensity.

FIGURE 37-2 Ultrasound-guided aspirations are performed by using asyringe holder and preferentially a 0.6 × 25 mm needle. The needle shouldbe introduced 0.5 to 1.0 cm from the middle of the long axis of the 7.5- to10-MHz linear array transducer.

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of the neck has been extensively discussed in Chapter 33.In this chapter, selected topics will be discussed; inparticular, potential applications and limitations of ultra-sound will be indicated, along with anatomic features ofeach structure.

Thyroid Gland

The thyroid gland consists of two lateral lobes connectedby a median structure, the isthmus, at the junction of thelower and middle thirds of each lobe (Fig. 37-3). Theconcave posterior surface of the thyroid is applied againstthe anterolateral surfaces of the larynx and the first trachealrings. Average lobe dimensions are: height, 4 to 6 cm; widthand thickness, 1 to 2 cm. Ultrasound allows volumetricanalysis of the thyroid lobes. Each lobe can be considered asa separate sphere whose volume is given by v = (π/6 × height× width × depth). The average volume has been estimated atbetween 12 and 40 cm3. The average distance between theinferior lobe and the sternum may be 1 to 2 cm, but thisposition varies from one individual to another. If the caudalextreme is much lower, the neck should be extendedconsiderably for accurate examination. The thyroid lobes are

often slightly asymmetric, with the right lobe tending to belarger than the left. The isthmus may vary from 1 to 2 cm inheight. The pyramidal lobe is an inconstant conical structureprojecting upward from the isthmus, either along the midlineor off to one side. Normal thyroid parenchyma has acharacteristic sonographic appearance of homogeneousmedium-level echoes, with little identifiable internal archi-tecture. The use of color Doppler imaging identifies multiplesmall vessels within and adjacent to the thyroid gland. Partsof the paired superior and inferior thyroid arteries, whichprovide the blood supply to the thyroid, can usually bevisualized as they enter the gland.

The esophagus often projects to the left of the trachea andmay be seen at the posteromedial border of the left thyroidlobe. The esophagus is visualized sonographically as asemicircular bull’s eye with a hyperechogenic center(esophageal lumen) and less echogenic contours (esopha-geal wall). However, this image may vary. An esophagealdeviation to the left side of the neck should not be mistakenfor a cervical mass. The mobility of this structure can beexamined by having the patient swallow.

As the internal jugular vein is not always spontaneouslyvisible, a Valsalva maneuver can be performed to dilate thejugular vein. The vagus nerve lies in the posterior angle ofthe common carotid artery and the internal jugular vein (Fig.37-4). The posteromedial border of each thyroid lobe isintimately related to the corresponding recurrent laryngealnerve. Enlargement of the thyroid gland, especially ifsecondary to malignancy, may cause paralysis of the vocalcord.FIGURE 37-3 Thyroid gland. The thyroid gland consists of two lateral

lobes (arrows) connected by a median structure, the isthmus. This axialimage shows thyroid tissue as highly uniform tissue with medium-levelechogeneity, with little identifiable internal architecture. Small, dilatedveins may be visualized as small, rounded structures or as small, linearstructures. The concave posterior surface of the thyroid is located adjacentto the first tracheal rings.

FIGURE 37-4 The major neurovascular bundle comprises thecommon carotid artery, the internal jugular vein (lateral to the artery andmore or less spontaneously visible), and the vagus nerve. This axial imagelow in the neck shows both vascular structures, lateral to the thyroid lobeand deep to the sternocleidomastoid muscle.

Chapter 37 Ultrasound of the Neck 1937


Parathyroid Gland

In most people there are four parathyroid glands (twosuperior and two inferior ones) dorsal to the thyroid glandand its capsule. In approximately 5% of people there aremore than four glands. Normal glands are oval orbean-shaped. The normal parathyroid gland averages 3 to 6mm in length, 2 to 4 mm in width, and 1 to 3 mm inthickness. However, normal parathyroid glands cannot bevisualized because they have an echogenicity similar to thatof the thyroid gland. Normally positioned parathyroidglands are characteristically located around the terminalbranches of the inferior thyroid artery. Superior glands arelocated behind the upper pole or midportion of each thyroidlobe. The inferior glands are usually located just inferior tothe posterior aspect of the lower thyroid poles. If they fail todissociate from the adjacent thymus during development,they may migrate more inferiorly into the superior mediasti-num. Most frequent sites of ectopic glands are mediastinal,retropharyngeal, or retroesophageal.

Salivary Glands

The parotid gland is the largest salivary gland and isbounded anteriorly by the ascending ramus of the mandibleand posteriorly by the mastoid process (Fig. 37-5). Thisgland has a homogeneous, hyperechoic appearance. Ultra-sound cannot visualize the portion of the gland that extendsdeep to the mandible. The facial nerve emerges from theskull through the stylomastoid foramen. It enters thesuperior deep portion of the parotid gland anterior tothe posterior belly of the digastric muscle. As the nervecourses inferiorly, it is located lateral to the retromandibularvein. After crossing the vein, the facial nerve divides into itsbranches. The facial nerve is encased in a fibrous sheath thatis easily recognized by the surgeon but is indistinguishable

sonographically from surrounding parotid gland tissue.3 Theexternal carotid artery may be visible sonographically,terminating 4 cm above the angle of the mandible, where itdivides into the maxillary and superficial temporal arteries.Lymph nodes are also located in the parotid gland. Normalintraparotid lymph nodes cannot be visualized by ultraso-nography.

The submandibular gland (Fig. 37-6) is located in thesubmandibular region. The submandibular duct (Wharton’sduct) emerges from the gland’s superior surface andterminates at the side of the frenulum of the tongue. Theentire submandibular gland can be seen by ultrasound, withan appearance similar to that of the parotid gland.

The Neck (Cervical Lymph Nodes)

Familiarity with the normal anatomy and features of thecervical nodes is essential for complete evaluation ofpatients with head and neck malignancies. Of the estimated800 lymph nodes in the human body, 300 are situated in theneck. Until recently, the regional categorization of lymphnodes, as described by Rouviere, was the most widely usedfor lymphadenopathy.4 Today, most centers use the classifi-cation into levels proposed by the Memorial Sloan-KetteringCancer Center and described by Som5 (Fig. 37-7). Also seeChapter 36 for updated classifications.

In this classification system, level I corresponds to thesubmandibular and submental regions. Levels II, III, and IVcorrespond to the jugular chain nodes around the internaljugular vein (high, mid-, and low jugular). Level II issituated above the level of the hyoid bone. Level III liesbetween the bottom of the body of the hyoid bone and the

FIGURE 37-5 This axial image shows the parotid gland (curvedarrows) with a homogeneous, hyperechoic appearance. Ultrasound cannotvisualize the part of the deep portion of the gland that extends deep to themandible (straight arrows), which is the anechogenic area on this image.

FIGURE 37-6 This frontal image shows the submandibular glandadjacent to the anechoic mandible (curved arrow), with a homogeneousappearance similar to that of the parotid gland. The entire gland can be seenby ultrasound. Submandibular ducts (small arrows) may be visualizedinside the gland.

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crossing with the omohyoid muscle and the jugular vein (orthe bottom of the cricoid cartilage arch). Level IV liesunderneath this crossing and above the clavicle. Level Vrepresents the lymph nodes posterior to the posterior borderof the sternocleidomastoid muscle (posterior triangle) andabove the clavicle (supraclavicular). The trapezius muscleforms the posterior border of this level. Level VI corre-sponds to the juxtavisceral, such as the paratracheal lymphnodes. The superficial, facial, parotid, nuchal, and retropha-ryngeal lymph nodes that were recognized by Rouviere arenot outlined in this scheme, as these are not commonlyremoved in neck dissections.

Although many different pathways and anastomoses ofthe lymphatics in the neck exist, most primary tumorsmetastasize via predictable routes following local anddeep lymphatic pathways.6 The primary echelon lymphnodes, that is, the sentinel lymph nodes, are at highest riskof harboring occult metastases in an N0 neck. For anteriororal and nasal cavity as well as lip carcinomas, level I isat highest risk. In posterior oral cavity and oropharyn-geal tumors, level II lymph nodes are at highest risk,whereas in laryngeal and hypopharyngeal tumors, levels IIand III can both harbor the sentinel lymph node. Hypo-pharyngeal and proximal esophageal as well as subglottictumors can also spread to the paratracheal nodes in an earlystage. Tumors from the skin of the face and scalp oftenspread to parotid, facial, or nuchal lymph nodes. For theradiologist, it is important to look for lymph nodesespecially in the first echelon, and if ultrasound-guidedFNAC is used, preferably to aspirate from lymph nodes inthese regions.

ULTRASONOGRAPHY OF NECKPATHOLOGY

Thyroid Gland

The thyroid gland is ideally situated for high-frequencysonography due to its superficial location. High-resolutionultrasound permits excellent visualization of the thyroidparenchyma. Ultrasound is generally the first choice forevaluation of thyroid morphology because of its sensitivityin detecting both small nodules and subtle variations likenodularity, calcifications, septations, and cyst formations.Many thyroid nodules discovered incidentally at sonographymay not be clinically significant.7 Sonography is anexcellent tool for evaluating the thyroid gland to assess thevolume of thyroid tissue, to provide image guidance forpunctures and follow-up during and after therapy (thyroid-ectomy or prior neck irradiation). Ultrasound is lessexpensive than scintigraphy, allows easier comparisonduring follow-up, and has no accompanying radiationexposure or intravenous injections.

Diffuse Thyroid DiseaseGeneralized thyroid enlargement, or goiter, may be

caused by a number of distinct entities, including multinodu-lar goiter, Graves’ disease, Hashimoto’s thyroiditis, andinfectious thyroiditis.8, 9 A goiter is simply an enlargedthyroid gland, which may be seen with hyperthyroidism orhypothyroidism. Multiple hyperplastic nodules exhibitingvarying degrees of colloid, necrosis, or hemorrhage charac-terize pathologically multinodular goiter (Figs. 37-8 and37-9). Generally, laboratory values, the clinical history, andthe physical examination differ in these entities. However,ultrasound findings may demonstrate mixed solid and cysticzones within an enlarged nodular thyroid gland. Calcifica-tions may occasionally be present.10 Sonography providesinformation regarding the size of the thyroid gland, diseaseextent, and surrounding lymphadenopathy. The incidence ofcarcinoma in a multinodular goiter is very low (less than3%), and on scintigraphy the characteristic appearance ofmultiple cold areas interspersed with hot areas in a largegland will usually obviate the need for aspiration. A large,

FIGURE 37-7 Anatomic classification of cervical nodes according tothe American Academy of Otolaryngology. Level 1: submandibular andsubmental region; level 2: high jugular or subdigastric; level 3: midjugular;level 4: low jugular; level 5: posterior triangle; level 6: juxtavisceral.

FIGURE 37-8 Multinodular goiter. Both lobes of the thyroid gland areenlarged, and are seen with moderate heterogeneity (mainly solid).



dominant, hard, or growing mass amid a goiter shouldprobably be sampled. Serial ultrasound examination canmonitor the disease progression and the therapeutic re-sponse.11, 12

Graves’ disease (diffuse toxic goiter) is characterizedclinically by signs and symptoms of thyrotoxicosis andenlargement of the thyroid gland (Fig. 37-10). The mostcommon cause of hyperthyroidism, Graves’ disease is anautoimmune disorder mostly found in women. Carcinoma ofthe thyroid gland in a patient with Graves’ disease is rare,reported in only 0.15% to 0.5% of patients. The gray-scalesonographic pattern ranges from normal echogenicity todiffusely hypoechogenic. The thyroid tends to be moreheterogeneous in patients with multinodular goiter than inpatients with Graves’ disease. The diagnosis is madeclinically. Color Doppler imaging of the thyroid glandaffected by Graves’ disease may show a striking pattern ofincreased vascularity, both in systole and in diastole.13 Somestudies suggest that thyroid vascularity and thyroid arteryblood flow are significantly higher in the active stage ofGraves’ disease. These findings suggest that color Dopplercould be a useful marker for inflammatory activity,independent of hormone production.14

Another cause of thyroid enlargement is Hashimoto’sthyroiditis, the most common form of thyroiditis (Fig.37-11). It is mostly found in middle-aged women as apainful, diffusely enlarged gland. Gland size may also benormal. About 50% of patients are hypothyroid. The diseaseshows no greater risk of thyroid carcinoma, but patientsappear to be at greater risk of developing non-Hodgkin’slymphoma. On ultrasound, the thyroid gland is enlarged andhypoechoic. Multiple ill-defined hypoechoic areas separatedby thickened fibrous strands may be seen. A diffusemicronodular pattern is suggestive of Hashimoto’s disease.However, the diagnostic accuracy of this finding has notbeen reported.15 The final diagnosis still requires serologictests. An enlarged thyroid gland may also be seen with acuteinfectious thyroiditis. Ultrasound may be useful for patientswith a painful thyroid gland, particularly those with focaltenderness, to evaluate for the presence of a thyroid abscess.

Focal Thyroid DiseaseNodular disease in the thyroid gland is characterized by

the presence of one or more palpable or nonpalpable nodules(Fig. 37-12). In the general population, thyroid nodules areexceedingly common. Noncystic nodules were detected onsonography in about 20% in a large prospective study ofpatients who had a normal thyroid gland on palpation.Clinical assessment is generally considered to be unreliablein attempting to differentiate a benign from a malignantnodule. The primary role of scintigraphy in the evaluation offocal thyroid masses is to determine whether a lesion is‘‘hot’’ (a relatively low incidence of malignancy: less than5%) or ‘‘cold’’ (a relatively high incidence of malignancy:20% to 30%).16 The low accuracy of radionuclide scanninghas led to an effort to define reliable sonographic criteria todifferentiate between malignant and benign thyroid nodules.

High-resolution ultrasonography can detect very smallnodules. However, no single sonographic criterion enablesreliable differentiation between benign and malignantthyroid nodules.9, 11, 14, 17, 18 Nevertheless, there are certainfindings that can help to make this important differentiation.The presence of microcalcifications is highly suggestive ofmalignancy.18 An irregular, thick margin, especially in thepresence of a halo or microcalcification, suggests malig-nancy.14 Ultrasonography is accurate in distinguishing solidfrom cystic thyroid nodules. Malignant thyroid cysts arerare. Most cystic masses arise from preexisting solid nodulesand are therefore complex.19 The presence of colloidmaterial within the cyst can cause a series of closely spaced,discrete echoes (a particular form of reverberation), theso-called comet tail artifact. Conversely, the presence ofcoarse calcifications, a regular margin, and a thin-rimmedanechoic cyst with a well-defined halo suggests benig-nity.19–22 Multiplicity of nodules has not been shown toaffect the likelihood of malignancy.23 There may beconsiderable overlap in the sonographic appearance of

FIGURE 37-9 Multinodular goiter. The thyroid gland is minimallyenlarged. A large cystic lesion is located in the right lobe of the thyroid.

FIGURE 37-10 Graves’ disease. Diffuse enlargement of both lobes(curved arrows) of the thyroid gland is present. The thyroid gland has lowechogeneity.

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benign and malignant nodules. Therefore, caution should beused in relying on sonographic features alone to characterizethyroid nodules. There are also many similarities in theappearances of benign and malignant nodules on colorDoppler imaging.24 Often an ultrasound-guided puncture isrequired to obtain cytologic evidence.

During routine ultrasound examination of the neck,nonpalpable (incidental) thyroid nodules that are less than 1cm in diameter may often be detected.14 The question arisesas to what should be done with the many unsuspected,mostly benign thyroid nodules. Radiologists should befamiliar with the above-mentioned morphologic featuresthat increase the probability of malignancy. Based on thework of several authors,25, 26 an algorithm for dealing withincidental nodules was developed. Patients with nodules atleast 1.5 cm in size, or with nodules with suspiciousultrasound features or a history of thyroid cancer, shouldundergo ultrasound-guided FNAC. Patients with nodulessmaller than 1.5 cm, or with nodules with benign-appearingfeatures and without a history of thyroid cancer, can befollowed by physical examination. If during follow-up thenodule is found to be increasing in size, patients shouldundergo ultrasound-guided FNAC. Most papillary carcino-mas, which account for 55% to 75% of thyroid cancer, growslowly and remain definitely curable if and when theybecome clinically apparent at approximately 1.0 to 1.5 cm insize.

Percutaneous Aspiration Under Ultrasound GuidanceFNAC has a major role in the management of palpable

thyroid nodules because of the absence of reliable clinical orultrasonographic criteria for differentiation of benign frommalignant thyroid nodules.14 Aspiration findings can beclassified as benign (no evidence of malignancy), suspicious(features suggestive of but not diagnostic for malignancy,including Hurthle cell neoplasms and follicular neoplasms),

malignant (definite evidence of papillary, anaplastic, ormetastatic cancer), or nondiagnostic. Regarding the majorityof palpable thyroid nodules, FNAC can be performed underpalpation guidance with a high degree of accuracy (up to85%). Ultrasound-guided FNAC has been reported to havehigher accuracy than conventional FNAC.27 Ultrasound-guided FNAC is useful for patients in whom conventionalFNAC was not successful; for patients with suspicious,nonpalpable nodules; and for patients with a worrisomeclinical history, such as significant neck irradiation. Approx-imately 60% of the nondiagnostic, palpation-guided nodulebiopsies are reported to be diagnostic when repeated usingultrasound guidance.9

Tumor Recurrence After ThyroidectomyWhole body scanning using radioiodine has traditionally

been the mainstay in diagnosing recurrent tumor followingsurgery. However, Antonelli et al. have reported thatultrasound is capable of detecting recurrent tumor in thethyroid bed as well as cervical lymph node metastasis28 (Fig.37-13). Some studies suggest that ultrasound may havehigher diagnostic accuracy than scintigraphy.29 Routineultrasonography may be used for follow-up of patients withthyroid cancer.14 Because of the considerable overlap in thesize and appearance of benign and malignant lymph nodes,we recommend percutaneous ultrasound-guided FNAC ofall suspicious lymph nodes.

Ultrasound-Guided Sclerotherapy of Thyroid CystsTrue thyroid cysts can be punctured and aspirated.

However, these cysts will very often regain their originalsize within a few days. An alternative approach is to sclerosethe cyst wall by injecting absolute ethanol or tetracyclinehydrochloride. After aspiration of the cystic fluid with a22-gauge needle, approximately one-half to two-thirds ofthe original volume is replaced by a sclerosing agent. Asmall amount of saline is injected before the needle is

FIGURE 37-11 Hashimoto’s thyroiditis. The thyroid gland is symmet-rically enlarged (straight arrows), as noted especially at the isthmus (curvedarrow). The gland has an overall homogeneous, hypoechoic appearance.Multiple ill-defined hypoechoic areas are separated by thickened fibrousstrands.

FIGURE 37-12 Euthyroid patient. The right lobe of the thyroid isalmost entirely replaced by a large cystic nodule, which proved to behemorrhagic.



retracted. In this manner, pain due to spilling of thesclerosing agent in the surrounding tissue is avoided. Inapproximately 80% to 90% of cases, the cyst will be reducedin size or disappear. Large cysts respond better than smallcysts.30

Parathyroid Gland

Primary HyperparathyroidismThe main indication for ultrasonography of the parathy-

roid glands is the evaluation of patients with hypercalcemia.Hypercalcemia is a fairly common disorder that may occurin the absence of clinical symptoms in 1 out of 1000 cases.About 80% of cases are related to hyperparathyroidism.Females are affected twice as often as males, and althoughthe condition can occur at any age, most patients are over 40years of age.31 Primary hyperparathyroidism is caused by anexcess of parathyroid hormone secretion by a parathyroidadenoma (nearly 80% of cases and almost always limited toone gland), hyperplasia (less than 20% of cases and affectingall four glands), or carcinoma (only 1% and affecting onegland).

The typical parathyroid adenoma may be seen in a patientwith biochemical evidence of hyperparathyroidism as anoval, solid mass of homogeneously low echogenicity. Thesize of the adenoma usually ranges between 0.8 and 1.5 cmin length; however, larger lesions may occasionally beencountered.32 They may occasionally be multilobular andheterogeneous and may contain internal calcification orcysts.33 An echogenic line separating thyroid and parathy-roid tissue may allow the distinction between adenoma andadjacent thyroid.

The sensitivity of sonography for localizing parathyroidadenomas in patients with primary hyperthyroidism has

been reported to range between 70% and 80%.34, 35

Sonographic examination of a patient with hyperparathy-roidism may give a false-negative result in three situations:minimally enlarged adenomas, adenomas displaced andobscured by an enlarged thyroid goiter, and adenomas inectopic parathyroid glands located in regions difficult toevaluate by ultrasonography. Such areas include locationsbehind air-containing viscera (pharynx, esophagus) or bone(sternum, clavicle).

Posterior exophytic thyroid nodules and cervical lymphnodes may cause false-positive sonographic results. Thyroidnodules have mixed echogenicity, including cystic andcalcified components, and are usually intrathyroid. Lymphnodes may contain a characteristic hilum and are generallymore lateral in the neck. Ultrasound-guided FNAC may beperformed to differentiate suspected parathyroid adenomasfrom lymph nodes and thyroid nodules.

Imaging IndicationsRoutine preoperative imaging is not performed because

morbidity is rare when an experienced surgeon performsparathyroidectomy. Ultrasound may occasionally be used inpreoperative evaluation of patients with primary hyperpara-thyroidism. Unilateral parathyroid exploration with ade-noma removal and identification of a normal parathyroidgland is an accepted surgical approach for the treatment ofpatients with primary hyperparathyroidism. In experiencedhands, high-resolution sonography can be a cost-effectivemeans of localizing parathyroid adenomas when unilateralexploration is considered an accepted surgical approach.36

In contrast, preoperative imaging may be beneficial inpatients undergoing a second surgical procedure forpersistent or recurrent hyperparathyroidism (Fig. 37-14). Inthis patient group, ultrasound has demonstrated highersensitivity (60% to 82%) than MR imaging or CT.37

Ultrasound may also be used to guide the fine-needleaspiration of suspicious lesions.

FIGURE 37-14 Recurrent hyperplasia of the parathyroid gland.Dorsally to the right lobe of the thyroid gland, an enlarged parathyroidgland (arrows) is demonstrated, with low and somewhat inhomogeneousechogenicity.

FIGURE 37-13 Tumor recurrence after thyroidectomy. A large,inhomogeneous mass (curved arrows) is found in the left lobe of thethyroid adjacent to the trachea (straight arrow).

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SALIVARY GLAND

Sialolithiasis

Inflammatory disease can be best investigated by othermodalities, such as CT or sialography, and is not anindication for ultrasound. However, ultrasound may bebeneficial for evaluating patients with sialolithiasis. Plainfilms or CT are usually performed first. If they are negative,sialography remains a reliable method for detectingsialolithiasis.38 Ultrasound is a noninvasive method fordetecting calculi and assessing the surrounding parenchyma.A dilated duct can be identified, as can nonradiopaquecalculi. Ultrasound may detect calculi in up to 91% ofcases.39 It may also be helpful when ductal cannulation isimpossible.

Tumors and Tumor-Like Conditions

Tumors are 10 to 15 times more common in the parotidgland than in the submandibular glands. Benign lesionsaccount for about 80% of all parotid tumors. In contrast, thefrequency of malignant tumors in the submandibular glandis much higher (approximately 33% to 50%). Pleomorphicadenoma is the most frequent tumor (60% to 70%) of thesalivary glands. Warthin’s tumor, also called adenolym-phoma, accounts for 6% to 10% of all parotid tumors. Only5% of cases are bilateral. Benign nonepithelial tumors mayarise within glandular spaces and include lipomas, schwan-nomas, and vascular tumors. Like benign tumors, epitheliallesions are the most frequent forms of malignancy.Metastases and lymphomas of the salivary glands are rare.Pleomorphic adenomas have a tendency to recur if thecapsules are damaged at surgery. For that reason, partial ortotal parotidectomy should be performed. Warthin’s tumorhas an excellent prognosis and almost never recurs;malignant degeneration is extremely rare. Therefore, enucle-ation or continuous follow-up without removal may besufficient.

High-resolution ultrasound is considered by some au-thors to be the modality of first choice for detection ofneoplasms in the salivary glands. However, ultrasound isunable to evaluate that portion of the parotid gland situateddeep to the mandible. If the lesion needs to be identifiedbefore surgery, ultrasound-guided FNAC may be per-formed. MR imaging is an important adjunct for evaluatingthe full extent of tumor and evaluating for perineural spread.In cases of malignancy, the neck should also be examinedfor enlarged lymph nodes.

Pleomorphic AdenomaApproximately 90% of pleomorphic adenomas are

located in the superficial lobe (Fig. 37-15). Consequently,ultrasonography may detect the large majority of theselesions. The possibility of malignant transformation ofpleomorphic adenomas remains controversial. Small (<3cm) pleomorphic adenomas are usually visualized as ahomogeneous, well-delineated, lobular nodule of decreasedsignal intensity compared to surrounding parotid glandtissue.40, 41 The absence of either sharp margins orhomogeneity may suggest malignancy. Reports from the

literature regarding the potential of color Doppler sonogra-phy to differentiate malignant and benign tumors arecontradictory.42, 43 Large tumors (>3 cm) are prone to cysticand hemorrhagic degeneration, which modifies their internalarchitecture. In cases of recurrent tumor, ultrasoundexamination may be hindered by echogenic scar. MRimaging is indicated in these cases.

Warthin’s TumorUltrasound shows a well-defined, anechoic mass or a

mass with multiple anechoic areas, often at the lower pole ofthe parotid40, 41 (Fig. 37-16). However, the pattern mayvary. In certain cases, multiple septa and the thickness of

FIGURE 37-15 Pleomorphic adenoma. Axial image shows a pleomor-phic adenoma as a somewhat lobulated, homogeneous area (curved arrow)in the parotid gland and adjacent to the mandible (straight arrow).

FIGURE 37-16 Warthin’s tumor. Axial image shows a large,well-defined mass with multiple anechoic areas (arrows) and septa in theparotid gland adjacent to the mandible.



intratumoral fluid give an inhomogeneous echogenic pattern(Fig. 37-17). Because Warthin’s tumor may be bilateral, thecontralateral gland should always be examined carefully.

Malignant TumorsThere are many types of malignant epithelial tumors. The

most frequent are mucoepidermoid cancer (5% to 10% of allsalivary gland tumors), adenoid cystic carcinoma, acinic celltumors (Fig. 37-18), undifferentiated carcinoma, and epider-moid carcinoma. Malignant tumors may often showattenuated posterior echoes, heterogeneous internal echoes,or a polygonal shape. There are no consistent criteria todifferentiate between malignant and benign lesions. MRimaging is necessary to show the extent of disease,particularly to demonstrate perineural spread of tumortissue.

NODAL NECK DISEASE

Nonneoplastic Lymphadenitis

As the neck lymphatics play a key role in upperaerodigestive tract infections, reactively enlarged lymphnodes are very common (Fig. 37-19). Most often these arecaused by viral or bacterial infections. The history, serology,and cultures of the primary infection, together withintracutaneous testing (e.g., Mantoux testing for mycobacte-ria), and, if needed, cytology can in general establish thediagnosis. However, ultrasound can sometimes help in thediagnostic workup of cervical lymphadenopathy. In suppu-rative lymphadenitis, the assessment of abscess formationand eventually ultrasound-guided drainage can be of greatimportance.44 In this respect, the hypervascularity shownusing Doppler sonography is a reliable diagnostic criterion.In a study of 50 lesions, a peripheral blood flow patternwas observed only in abscesses. Other patterns, such as amixed pattern (flow within and around the lesion) and acentral pattern (flow in the central region of the mass), wereseen most frequently in lymphadenitis but were not specificfor that diagnosis.45 Ultrasound-guided drainage is espe-cially useful if the abscess is located deep and is difficult toreach surgically.46, 47 For this indication, CT-guided drain-age can be used as well. A single mass with central heteroge-neous reflection patterns is most often caused by a suppura-tive lymph node, an (atypical) mycobacterial infection, orcat-scratch disease caused by Bartonella henselae. Multipleenlarged, conglomerate lymph nodes that are hypoechoic orhave inhomogeneous echotexture with enhanced through-transmission may be indicative of tuberculous lymphade-nopathy (Fig. 37-20). In these cases, nonspecific abscess-forming lymphadenitis, lymph node metastases, andmalignant lymphoma still should be excluded.48, 49 Bilateraldiffuse lymph node enlargement without necrosis is mostfrequently caused by viral infections, such as mononucleo-sis, herpes, cytomegalovirus, rubella, or HIV. HIV infec-tions can also present with cystic lesions in the parotid

FIGURE 37-17 Warthin’s tumor. Axial image shows a small,well-defined mass (curved arrow) in the superficial lobe of the parotidgland and adjacent to the masseter muscle (straight arrows).

FIGURE 37-18 Acinic cell carcinoma. Axial image shows a masswith heterogeneous, low echogeneity in the parotid gland.

FIGURE 37-19 Reactive lymph node. A reactive enlarged node with ahomogeneous pattern is identified in the submandibular region close to themandible (M).

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glands or with associated malignancies. Toxoplasmosis andsarcoidosis are rare causes of multiple cervical nodal en-largement. In sarcoidosis the salivary glands can be swollen,and a chest x-ray may reveal mediastinal lymph node en-largement. The diagnosis is made by serologic tests (angio-tensin converting enzyme, muramidase), bronchial lavage,and histopathology. In cases of single or multiple nodal en-largements with homogenous reflection patterns, Castle-man’s disease should be in the differential diagnosis.50

Malignant Lymphomas

Hodgkin’s and non-Hodgkin lymphomas can presentwith multiple or single abnormal nodes in the neck, either asthe initial presenting symptom or as part of a more general-ized disease. Ultrasound shows clearly delineated lymphnodes with a homogeneous, weak internal echo pattern, al-though spotty or dendritic hyperechoic areas can sometimesbe seen. Power Doppler sonography shows highly perfusednodes with color signals in the center as well as in the nodalperiphery in most lymphomas. However, this flow patternwith a reduced resistance index is not specific. It is reportedthat contrast-enhanced Doppler sonography can be useful indifferentiating lymphoma from reactive nodes.52

Metastatic Lymphadenopathy

Metastases to the cervical lymph nodes most frequentlyoriginate from squamous cell carcinomas of the mucosallining of the upper aerodigestive tract. Other primary sites ofmetastases are salivary gland, thyroid, and skin neoplasms.Metastatic patterns from skin melanomas differ from and aremore variable than metastases from mucosal carcinomas.53

Metastases from skin tumors are more often located in thesuperficial lymph nodes, such as those in the parotid gland,the nuchal area, or the posterior triangle. Their appearanceon ultrasound, CT, and MR imaging is identical to that of

squamous metastases, although melanoma metastases aremore often hypervascular. Well-differentiated thyroid carci-nomas have a very high rate of neck metastases, althoughthese are often clinically occult. On ultrasound, everyslightly enlarged node should be regarded as suspicious.Discrete calcifications or internal cysts may occasionally beseen. Imaging has relatively little utility in the managementof papillary carcinoma in patients with N0 necks since thetreatment is radioactive iodine.

Head and neck squamous cell carcinomas metastasizeprimarily to the cervical lymphatic system. The number andextent of metastases are important for the prognosis.Whereas only 7% of patients without lymph node metastasesdevelop distant metastases, almost 50% of patients withmore than three tumor-positive lymph nodes do so.53

Palpation is the most widely used staging technique for theneck, but its sensitivity and specificity are both between 60%and 70%. As a consequence, there is a substantial risk ofclinically occult metastases.54, 55 For T1 to T3 oral,oropharyngeal, and supraglottic tumors, the risk of occultmetastases is between 20% and 50%. In many head and neckprimaries, both the ipsilateral and contralateral sides are atsubstantial risk of developing nodal metastases. The riskincreases further if the primary has grown close to or extendsacross the midline.

Imaging can play a significant role in the staging andmanagement of cervical nodal metastases. An accurateimaging method can help to detect occult metastases in theclinically N0 neck or to lower the risk of occult metastasis.In the latter case, one should realize that imaging can onlydecrease the risk of occult metastases; it can never reducethe risk to zero. In general, ultrasound is reported to besuperior to palpation in detecting lymph node metasta-ses.56, 57 Whereas some authors report ultrasound to besuperior to contrast-enhanced CT and MR imaging,57, 58

others have found similar accuracy rates.56, 59 Ultrasoundexamination of level I is assumed to be more difficultbecause of the presence of the submandibular gland andartifact caused by the adjacent mandible (Fig. 37-21).

FIGURE 37-20 A and B, Tuberculous lymphadenopathy. Multiple enlarged, conglomerating lymph nodes thatare hypoechoic, with enlarged through-transmission, are seen. This large submandibular node appears to be partlycalcified (arrow). (Courtesy of Dr. F.B.L.M. Joosten.)



In patients with palpable suspicious lymph nodes, the roleof imaging is quite limited, although it can help determinethe tumor extent. If lymph nodes are fixed to the deepstructures, most authors cite preference for CT or MRimaging to assess the extent of the tumor. However, it hasbeen reported that ultrasound, in combination with palpation(i.e., sonopalpation),60 can identify carotid wall invasion.The accuracy of ultrasound and other imaging techniques forthe neck is dependent on the diagnostic criteria used inassessing for lymph node metastases.61, 62 Although theresolution has improved in recent years, it is still notpossible to detect small tumor deposits within lymph nodes.

Diagnostic criteria include an increased size, a roundershape, and the presence of irregular ultrasound reflectionpatterns caused by the tumor or by tumor necrosis orkeratinization (Table 37-1). An echogenic hilus can be seenin 60% of nonmetastatic nodes and is not present in lymphnodes totally replaced by tumor. However, the hilus canremain when small tumor deposits are present. Focal corticalwidening by tumor is reported to be a reliable criterion, as isa cystic pattern.63, 64 In general, a round shape is consideredmore suspicious than an oval or flat shape.65, 66 In reactivenodes, a transverse to longitudinal ratio of less than 0.5 ispresent in more than 80% of the cases.67 However, most ofthe characteristic ultrasound features cannot be appreciatedin lymph nodes smaller than 1 cm. As a consequence, for theclinically N0 neck, the size of lymph nodes remains animportant criterion as well.66 In this respect, the minimaldiameter is the preferred axis to measure. However, any sizecriterion is a compromise, as a small cutoff point has highsensitivity and low specificity and vice versa. In a recentstudy on the ultrasound size criteria in the N0 neck,69 it wasshown that the often used 1-cm criterion provides a lowsensitivity for this patient category. For level II nodes, a sizecriterion of 7 mm was optimal, whereas for the rest of theneck, lymph nodes with a minimal diameter of 6 mm wereconsidered suspicious. In spite of these refinements, it isclear that size, shape, and irregular echo patterns are not veryaccurate for the clinically N0 neck.

In recent reports on power Doppler sonography, aparenchymal blood flow signal throughout the entire lymphnode was present in over 80% of the larger metastatic lymphnodes, whereas reactively enlarged lymph nodes showedcharacteristic hilar perfusion.70 Other characteristics thathave been reported in metastatic lymph nodes includeavascular areas, displacement of intranodal vessels, aberrantcourse of central vessels, and accessory peripheral vessels.71

However, again with the use of Doppler sonography, it is notpossible to make a histopathologic diagnosis, and someauthors found skepticism about the applicability of thismodality.72, 73 Administration of galactose-based ultrasoundcontrast may improve the assessment of hilar and otheradjacent vascularity. However, measured Doppler indicesdo not add to the criteria for a differential diagnosis. Acombination of peripheral parenchymal nodal flow, internalarchitecture, and size will probably be the most accurate.However, application of these criteria to small lymph nodesmay be impossible.

To enhance the accuracy of ultrasound, ultrasound-guided aspiration of lymph nodes has been used. To use thistechnique, considerable training is required.74, 75 It is, ofcourse, mandatory to be aware of the patterns of lymphaticspread from different tumors in order to select the lymphnodes at highest risk. It has been shown that ultrasound-guided FNAC has a very high specificity, approaching100%. To obtain a high enough sensitivity, lymph nodes assmall as 4 to 5 mm in the first two echelons should beaspirated. If ultrasound is used during follow-up, not onlythe size of the node is important, but also its evolution overtime. In a previous report, we found that the diagnosticaccuracy of ultrasound-guided FNAC had a sensitivity of73% and a specificity of 100% in N0 necks.59, 74 This wassignificantly better than the results obtained with CT or MRimaging. Only one other study compared ultrasound-guided

Table 37-1CRITERIA CONCERNING THE SIZE, SHAPE, ANDGROUPING OF LYMPH NODES, AS REPORTED BY

DIFFERENT AUTHORS

Author Criteria

Van den Brekel59 Ax-min 11 mm at level II or 10 mm elsewhereor a grouping of three or more measuring 8 to10 mm

Vassallo63 No size criterion; long/ax-min <2 or absence ofa hilus or focal cortical widening

Bruneton67 8 mm ax-max and long/ax-max <1.5

Stern97 15 mm at all levels

Som98 15 mm at levels I and II or 10 mm elsewhere

Mancuso99 8 mm retropharyngeal or 15 mm at all otherlevels

Hillsamer100 Grouping of three or more measuring 8to 15 mm

Friedman101 10 mm at all levels

Close102 30 mm ovoid shape or 10 mm round shapeor a grouping of two or more measuring 10to 30 mm

Steinkamp103 8 mm ax-min or 8 mm ax-max and long/ax-min <2

Tachimori104 5 mm minimal diameter and long/ax-min <2

Abbreviations: long, longitudinal diameter; ax-max, maximal axial diameter;ax-min, minimal axial diameter.

FIGURE 37-21 B-cell lymphoma. Adjacent to the mandible, a clearlydelineated lymph node with homogeneous low echogeneity is seen. Nohilar pattern can be seen. (Courtesy of Dr. F.B.L.M. Joosten.)

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FNAC to CT and MR imaging and found it to be superior aswell.76 Recently, however, in a multi-institutional studyusing ultrasound-guided aspiration, Takes et al. reported asensitivity of only 42% in the N0 neck.77, 78 However, in thisseries, only a few elective neck dissections were included inmost centers, and some patients were irradiated beforesurgery. Righi et al. found a sensitivity of 50%, which wasworse than the 60% for CT in their relatively small study.79

However, in their study, most false negatives were found atthe beginning of the study, and some of these involvedirradiated patients or non–squamous cell carcinoma patients.

As these different sensitivities at least shed doubt on theaccuracy of the technique, we recently started a study todefine the causes of false-negative results. Using verysensitive molecular markers for the detection of tumor cellsin the aspirate, preliminary results show that only a fewpositive aspirates are missed by the pathologist.80 Recently,the most likely nodal drainage of a particular tumor has beenidentified by injecting a radiotracer into the region of theprimary tumor and measuring the activity over various nodalregions. With the use of scintigraphic detection of thissentinel lymph node (Figs. 37-22 and 37-23) and subsequent

ultrasound-guided aspiration of the node, we found that it ispossible to aspirate from the sentinel node reliably and toconfirm its identity by scintillation counting of the aspi-rate.81 The aspirate is then examined for tumor cells. The useof sentinel node scintigraphy and the use of differentaspiration techniques or needles might thus further improvethe ultrasound-guided aspiration technique.

We have found ultrasound-guided FNAC to be highlyspecific and quite sensitive in detecting palpably occultmetastases. In selected patients who can be treated withtransoral excision for T1 and T2 oral, oropharyngeal, andsupraglottic carcinomas, we rely on the ultrasound-guidedFNAC findings and do not routinely treat the neckelectively. These patients are followed very meticulously,using ultrasound-guided FNAC at regular intervals duringthe first year. So far, our preliminary experiences with this‘‘wait and see’’ policy have been encouraging. Of the 77patients who underwent a transoral excision without necktreatment in the last 4 years, and who have been followed forat least 1 year, 14 have failed in the neck (18%). Ten of these14 were salvaged and are alive without tumor (a 71%salvage rate). This high salvage rate is certainly related tothe short delay of the diagnosis of these 14 neck failures.These figures compare favorably to those quoted in theliterature (Table 37-2).

The role of ultrasound in evaluating the posttreatmentneck is controversial. The use of ultrasound or duplexDoppler for the follow-up of the treated neck has beeninvestigated by several authors.82–86 Westhofen showed thatultrasound-guided FNAC was superior to CT in detectingneck recurrences after previous treatment.82

OTHER CERVICAL SITES: CONGENITALCYSTIC LESIONS AND NONNODALMASSES OF THE NECK

In neck masses of unknown etiology, ultrasound providesa noninvasive method that can help differentiate betweensolid and cystic masses and may help in identifying theorigin of a mass. Depiction of anatomic structures oftenallows differentiation of lymphadenopathy from tumors ofthe salivary glands or other soft tissues of the neck. Exact

Table 37-2REPORTS OF DIFFERENT AUTHORS WHO ADOPTED

A WAIT-AND-SEE POLICY FOR T1 ANDT2 ORAL CARCINOMAS

AuthorPatients

ObservedNeck

RecurrencesPatientsSalvaged

Kligerman105 33 11 (33%) 3 (27%)Ho106 28 10 (36%) 3 (30%)Fakih107 40 23 (57%) 7 (30%)Cunningham108 43 18 (42%) 9 (50%)McGuirt109 103 37 (36%) 22 (59%)Khafif110 396 90–95 (24%)* 53 (59%)Vandenbrouck111 36 17 (47%) 14 (82%)Van den Brekel112 77 14 (18%) 10 (71%)

Note: Only Van den Brekel et al. used ultrasound-guided FNAC in the initialassessment and follow-up.

FIGURE 37-22 The sentinel node procedure. Initially, technetium-99-labeled colloidal albumin should be injected around the tumor in three orfour locations.

FIGURE 37-23 Several minutes after injection of technetium-99, thefirst-echelon node may be located with a gamma camera on lateral andposteroanterior (PA) images. It is essential to obtain both PA and lateralimages; otherwise, the sentinel node may be missed by overprojection ofthe injection site.



localization of a mass, as well as typical ultrasound orDoppler sonography characteristics, can help differentiatebetween a primary mass such as a carotid body tumor and anenlarged lymph node.87, 88 Congenital cystic masses such asbranchial cleft cysts, thyroglossal duct cysts, and plungingranulas have a characteristic sonographic appearance.Extralaryngeal laryngoceles can be followed through thethyrohyoid membrane and can be filled with air as well asfluid. Ultrasound can also be used to guide aspirationcytology of small masses or masses in proximity to the largevessels.

Cystic Lesions

This section describes the cysts in the neck apart fromthose in solid organs: the thyroglossal duct cyst, ranula,branchial cyst, cystic lymphangioma, and dermoid cyst.

The thyroglossal duct cyst (Fig. 37-24) accounts for themajority of cystic neck lesions. The cysts may occur atalmost any age. They may be complicated by fistulas.Carcinomatous change occurs in 1% of cases. The anatomiclocation along the course of the thyroglossal duct usuallysuggests the diagnosis. The cysts may occur anywhere alongthe course of the duct remnant, from the base of the tongueto the suprasternal region, but most are located in the regionof the hyoid bone. Most commonly, they are located in themidline, but approximately 33% may be located slightly offmidline. The majority of off-midline cysts are locatedadjacent to the outer surface of the thyroid cartilage, deep tothe strap muscles. High-resolution ultrasonography remainsthe ideal imaging modality. The sonographic appearancemay vary from truly anechoic, to predominantly anechoicbut containing internal debris (due to proteinaceous con-tent), to a complex heterogeneous pattern and a uniformlyheterogeneous appearance.89 Posterior enhancement, acharacteristic feature of an uncomplicated cyst, is reportedto be present in approximately 90% of cases.89, 90 Often it is

difficult to identify this enhancement, particularly if thelesions occur in proximity to the airway. The cysts are welldefined. The walls may be thin, thick (probably due toinfection or cellular debris), or, rarely, imperceptible. Thepresence of a solid component is suspicious for carcinoma.Ultrasound-guided FNAC may not be necessary in patientsundergoing surgery.

Ranulas are of two types. The simple ranula occurs inthe floor of the mouth above the mylohoyoid muscle in theregion of the sublingual gland and is truly an epithelium-lined cyst. A ‘‘diving’’ or ‘‘plunging’’ ranula results afterthe rupture of the simple ranula’s wall. These arepseudocysts lined by dense connective tissue or granula-tion tissue. On ultrasound, ranulas are usually well-defined,cystic-appearing lesions. When simple they are confined tothe sublingual region. When diving, the bulk of thelesion is typically identified in the submandibular region(Fig. 37-25).

Branchial cysts can be classified on the basis of theirlocation (see Chapter 35). Superficial cysts may be seen inthe region of the parotid or anterior to the sternocleidomas-toid muscle. Deeper cysts are seen anterior to the greatvessels (type 2 is the most frequent type) (Fig. 37-26).Extensions between the carotid arteries and toward thepharyngeal wall can be followed on ultrasound. Branchialcysts are most commonly discovered in young adultsbetween 15 and 40 years of age. Clinically, branchial cystsappear rapidly over a period of several days as a mostlypainless swelling in the upper region of the neck. Less often,the diagnosis is suggested by a history of a recurrentinflammatory neck mass, always at the same location.Ultrasound can usually confirm the diagnosis of a branchialcyst. Branchial cleft cysts may be difficult to distinguishfrom thyroglossal duct cysts (Fig. 37-27). However, thecharacteristic location and FNAC are helpful in differentiat-ing the two cystic lesions.

A dermoid cyst is usually located at or near the midlinearound the hyoid bone. These cysts have an echogenic,

FIGURE 37-24 A, Thyroglossal duct cyst. Ultrasonography shows a large midline bilobular cystic lesionimmediately caudal to the hyoid bone. The sonographic appearance is anechoic. B, CT confirms the ultrasonographicfindings. (Courtesy of Dr. F.B.L.M. Joosten.)

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pseudosolid appearance similar to that of a thyroglossal ductcyst. Preoperative differentiation between the two is notnecessary, as this can be done at surgery.

Cystic hygroma and lymphangioma are discussed in thelast section of this chapter.

Infectious Disease

In our experience, ultrasonography should not be themodality of first choice when there is a suspicion ofinflammatory disease or abscesses in the neck. The

appearance of abscesses may be misleading on ultrasonogra-phy, and they may be underdiagnosed. We recommend CTfor confirming the diagnosis of a neck abscess or suppura-tive adenitis and for delineating the extent of disease. Inselected cases, ultrasound may be used to guide aspiration ordrain placement.

Lipomas

Lipomas are the most common benign mesenchymaltumor. They can arise in any location where fat is located.

FIGURE 37-26 Brachial cleft cyst. This lateral cyst (straight arrows)lies beneath the platysma anterior to the sternocleidomastoid muscle(curved arrow). (Courtesy of Dr. F.J.A. Beek.)

FIGURE 37-27 Thyroglossal duct cyst. Located near the midline, thishomogeneous lesion (arrow) has low echogeneity. (Courtesy of Dr. F.J.A.Beek.)

FIGURE 37-25 A and B, Plunging ranula. Coronal ultrasound demonstrates a multilobular cystic lesion in thesubmandibular space adjacent to the mandible (M) but extending beyond the mylohyoid muscle. The cysts are welldefined and are not truly anechoic due to their high protein content.



Fifteen percent of all lipomas occur in the head and neck.They are uncommon in children and most commonly presentin the fifth and sixth decades. They are multiple in 5% ofcases.

Clinical examination is often insufficient to identify thenature and exact origin of the mass, in which case imaging isnecessary. The sonographic appearance of head and neck li-pomas appears to be characteristic.91, 92 Ahuja and cowork-ers found that head and neck lipomas are compressible. Inmost cases they are well-defined, elliptical masses parallel tothe skin surface and hyperechoic relative to adjacent muscle.They typically have linear echoes at right angles to the ultra-sound beam and display no distal enhancement or attenua-tion.89 FNAC may be indicated if the diagnosis is not com-patible with clinical symptoms. CT or MR imaging may beindicated to show the extent of the mass.

The differential diagnosis of lipoma includes epidermoidcysts, branchial cleft cysts, thyroglossal duct cysts, heman-giomas, and lymph nodes. In epidermoid, branchial cleft,and thyroglossal cysts, the linear echogenic lines socharacteristic of a lipoma are not seen.91 Hemangiomas mayhave a similar shape and similar echogenic lines but arehypoechoic, with a heterogeneous echo pattern, and containcystic and sinusoidal spaces as well as the occasionalphlebolith.93 Normal nodes in the neck are hypoechoic andmay have an anechoic hilum. Nodes from papillarycarcinoma are hyperechoic relative to adjacent muscle.However, they do not have echogenic lines parallel to theskin surface.94

Neurogenic Tumors

Neurogenic lesions are relatively rare. The most com-monly encountered neurogenic tumors in the neck are

schwannomas, neurofibromas, and paragangliomas. Smallneurofibromas and schwannomas appear as solid nodules.However, the diagnosis can be obtained with high certaintyby performing MR imaging.

Color Doppler ultrasound may suggest the diagnosis ofparaganglioma by showing flow in the vascular channels andthe characteristic relationship of the mass to the carotid arter-ies (Fig. 37-28). Sonographic findings alone are insufficientfor a conclusive diagnosis of these tumors. In practice, thevalue of ultrasound appears limited compared to MR imag-ing and angiography for the diagnosis of paraganglioma.

THE ROLE OF ULTRASOUND FOREVALUATION OF INFANTS ANDYOUNG CHILDREN

Ultrasound examination of neck masses in infants andchildren is very useful and is often the initial imagingmodality.95, 96 It provides immediate information regardingthe location of a mass and determines whether the mass iscystic or solid. An indication of blood flow to the lesion canbe assessed by color Doppler. Ultrasound is especiallyuseful for soft, fluctuant masses (i.e., lymphangiomas,hemangiomas, and lipomas), because the ultrasonographicpattern of each of these lesions is quite distinct.

The characteristic appearance of many cystic lesions,including branchial cleft and thyroglossal duct cysts, hasbeen discussed. Cystic hygromas or lymphangiomas arepredominantly cystic, with multiple septations and locula-tions that can be variable in size.96 Hemangiomas are solidlesions and are the most variable of all of these lesionssonographically; the appearance depends mainly on the sizeof vascular lesions. Cavernous hemangiomas consist offeeding vessels and larger sinuses that are seen as round orlinear hypoechogenic areas within the otherwise echogenicmass (Fig. 37-29). Color Doppler imaging readily detectsflow within this type of hemangioma. Capillary heman-giomas usually consist of small vessels that are notclearly resolved with ultrasound, giving the lesion a coarse,echogenic aspect.96 Hemorrhage may occur often in lym-

FIGURE 37-28 Carotid body paraganglioma. A large mass withvascular channels (small arrows) fills the crotch of the carotid artery,splaying the external carotid artery (large curved arrow) and the internalcarotid artery (large straight arrow).

FIGURE 37-29 Cavernous hemangioma. Duplex Doppler ultrasonog-raphy shows a large, inhomogeneous lesion consisting of feeding vesselsand larger sinuses that are seen as round or linear vascular areas. (Courtesyof Dr. F.J.A. Beek.)

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phangiomas. If it is present, the normal anechoic fluid maybecome echogenic. Generally, CT or MR imaging is indi-cated in fluctuant lesions to demonstrate the extent of dis-ease, particularly infiltration of surrounding structures.96

Fibromatosis colli or fibroma is a common benign tumorin a young infant (Fig. 37-30). Ultrasonography often showsan oval echogenic mass located in the sternocleidomastoidmuscle. The clinical picture of torticollis combined with thisultrasound appearance secures the diagnosis.

In infants, carotid body tumors, malignant tumors of theneck such as sarcomas and neuroblastoma, may occur butare relatively uncommon. On ultrasonography, malignanttumors generally are echogenic, but if necrosis occurs,hypoechoic foci may be scattered throughout the tumor. CTand particularly MR imaging are usually required fordelineation of the tumor extent.

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FIGURE 37-30 Fibromatosis colli. Oblique coronal ultrasound-image (A) shows that part of the caudal area(curved arrow) of the sternocleidomastoid muscle is enlarged. The axial image (B) shows the abnormality in thesternocleidomastoid muscle (curved arrows), which is slightly inhomogeneous and isoechoic. (Courtesy of Dr.F.J.A. Beek.)



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