FRIDAY, MARCH 31, 2017

7:30 AM – 5:15 PM
Orange County Convention Center
Orlando, FL

Advanced
Hands-on Thyroid
Ultrasound Workshop
PROGRAM AGENDA 
7:30–7:40 AM  Welcome and Introduction 
7:45–8:10 AM  Understanding Ultrasound Principles & Physics to Optimize Imaging 
Lawrence Kim, MD 
8:10–8:35 AM  Normal Head & Neck Ultrasound Anatomy 
Jennifer A. Sipos, MD 
8:35–9:05 AM  Challenges in Sonographic Assessment of Thyroid Nodules 
Susan J. Mandel, MD, MPH  
9:05–9:30 AM  Ultrasound Interpretation of Non‐Thyroid Neck Pathology 
Kevin T. Brumund, MD 
9:30–9:45 AM   Q&A and Panel Discussion 
9:45–10:00 AM   BREAK 
10:00–10:25 AM  Sonographic Assessment of Cervical Lymph Nodes 
Peter J. Mazzaglia, MD 
10:25–10:45 AM  Ultrasound of the Vocal Cords 
    Denise M. Carneiro‐Pla, MD 
10:45–11:10 AM  Ultrasonography for Parathyroid Localization 
Carmen C. Solorzano, MD 
11:10–11:45 AM  Use of Ultrasound for Thyroid Cancer Surgical Planning 
Scott M. Wilhelm, MD 
11:45 AM–12:00 PM   Q&A and Panel Discussion 
12:00–12:15 PM  Live Patient Demonstration: Scanning Technique 
Susan J. Mandel, MD, MPH 
Denise M. Carneiro‐Pla, MD 
12:15–1:00 PM  LUNCH 

For the afternoon session, attendees will split into two groups. One group will attend an additional 
didactic session with an interactive activity and the other group with go to the hands‐on session. The 
groups will switch after 2 hours. 

1:00–3:00 PM  GROUP 1: ARS ACTIVITY IN LECTURE ROOM 
1. Thyroiditis/ATA Risk Category
Mark A. Lupo, MD 
2. Lymph Nodes/Microcalcifications
Denise M. Carneiro‐Pla, MD 
GROUP 2: DEMONSTRATION (ROOM W307 A‐C) 
1. Live Patient Demonstrations: Benign Thyroid Diagnosis
Jennifer A. Sipos, MD 
Giuseppe Barbesino, MD 
2. Live Patient Demonstrations: Malignant Thyroid Diagnosis
Kevin T. Brumund, MD 
Lawrence Kim, MD 
3. Fine‐Needle Aspiration Practice on Phantom Models
Jason L. Gaglia, MD, MMSc 
Stephanie L. Lee, MD, PhD 
4. Cytology and Slide Preparation
Nicole A. Massoll, MD 

3:00–3:15 PM   BREAK 
3:15–5:15 PM   GROUPS ROTATE 
5:15 PM   Adjourn 
FACULTY 
Course Co‐Directors 
Susan J Mandel, MD, MPH; Univ of Pennsylvania, Perelman Sch of Med 
Denise M. Carneiro‐Pla, MD; Med Univ of South Carolina 
Presenters 
Kevin T. Brumund, MD; Univ of California San Diego Moores Cancer Ctr 
Denise M. Carneiro‐Pla, MD; Med Univ of South Carolina 
Lawrence Kim, MD; Univ of North Carolina Sch of Med 
Mark A. Lupo, MD; Thyroid & Endocrine Ctr of Florida  
Susan J. Mandel, MD, MPH; Univ of Pennsylvania, Perelman Sch of Med 
Peter J. Mazzaglia, MD; Brown Univ 
Jennifer A. Sipos, MD; Ohio State Univ 
Carmen C. Solorzano, MD; Vanderbilt Univ Med Ctr 
Scott M. Wilhelm, MD; Case Western Reserve Univ Sch of Med 
Hands‐on Preceptors   
Giuseppe Barbesino, MD; Massachusetts Gen Hosp 
Kevin T. Brumund, MD; Univ of California San Diego Moores Cancer Ctr  
Jason L. Gaglia, MD, MMSc; Joslin Diab Ctr 
Lawrence Kim, MD; Univ of North Carolina Sch of Med  
Stephanie L. Lee, MD, PhD; Boston Med Ctr 
Nicole A. Massoll, MD; Univ of Arkansas for Med Sci 
Jennifer A. Sipos, MD; Ohio State Univ 
Special thanks to Ellie (Hawkinson) O’Brien and the Center for Education in Medicine at Northwestern 
University’s Feinberg School of Medicine for the development of the neck/thyroid models used in the 
practicum session. For more information, visit cem.northwestern.edu.  
 

ACCREDITATION STATEMENT 
The Endocrine Society is accredited by the Accreditation Council for Continuing Medical Education to 
provide continuing medical education for physicians.  
The Endocrine Society has achieved Accreditation with Commendation.  
The Endocrine Society designates this live activity for a maximum of 8.5 AMA PRA Category 1 Credits™ 
and 8.5 ABIM MOC points. Physicians should claim only the credit commensurate with the extent of 
their participation in the activity. 
 
 
 
 
 
 
 
LEARNING OBJECTIVES 
Upon completion of this educational activity, learners will be able to: 
• Review indications for an ultrasound examination of cervical lymph nodes in thyroid cancer 
patients 
• Demonstrate the imaging procedure and identify characteristics of benign and malignant lymph 
nodes 
• Discuss and illustrate the imaging characteristics of parathyroid adenomas 
• Practice specimen slide preparation and cytology interpretation 
 

TARGET AUDIENCE 
This continuing medical education activity should be of substantial interest to endocrinologists and 
other healthcare providers involved in the management of thyroid‐related disorders. 
 

STATEMENT OF INDEPENDENCE 
As a provider of continuing medical education (CME) accredited by the Accreditation Council for 
Continuing Medical Education, the Endocrine Society has a policy of ensuring that the content and 
quality of this educational activity are balanced, independent, objective, and scientifically rigorous. The 
commercial supporters of this activity have no influence over the planning of this CME activity. 
 

DISCLOSURE POLICY  
The faculty, committee members, and staff who are in position to control the content of this activity are 
required to disclose to The Endocrine Society and to learners any relevant financial relationship(s) of the 
individual or spouse/partner that have occurred within the last 12 months with any commercial 
interest(s) whose products or services are related to the CME content. Financial relationships are 
defined by remuneration in any amount from the commercial interest(s) in the form of grants; research 
support; consulting fees; salary; ownership interest (e.g., stocks, stock options, or ownership interest 
excluding diversified mutual funds); honoraria or other payments for participation in speakers' bureaus, 
advisory boards, or boards of directors; or other financial benefits. The intent of this disclosure is not to 
prevent CME planners with relevant financial relationships from planning or delivery of content, but 
rather to provide learners with information that allows them to make their own judgments of whether 
these financial relationships may have influenced the educational activity with regard to exposition or 
conclusion.  
The Endocrine Society has reviewed all disclosures and resolved or managed all identified conflicts of 
interest, as applicable. 
The faculty reported the following relevant financial relationship(s) during the content development 
process for this activity: 
Nicole A. Massoll, MD: Consultant, Arkansas Urology, Rosetta Genomics Ltd. 
 
 
The following faculty reported no relevant financial relationships: 
Giuseppe Barbesino, MD; Kevin T. Brumund, MD; Denise M. Carneiro‐Pla, MD; Jason L. Gaglia, MD, 
MMSc; Lawrence Kim, MD; Stephanie L. Lee, MD, PhD; Mark A. Lupo, MD; Susan J. Mandel, MD, MPH; 
Peter J. Mazzaglia, MD; Jennifer A. Sipos, MD; Carmen C. Solorzano, MD; Scott M. Wilhelm, MD 
The Endocrine Society staff associated with the development of content for this activity reported no 
relevant financial relationships. 
 

DISCLAIMERS 
The information presented in this activity represents the opinion of the faculty and is not necessarily the 
official position of the Endocrine Society. 
Use of professional judgment:  
The educational content in this activity relates to basic principles of diagnosis and therapy and does not 
substitute for individual patient assessment based on the health care provider’s examination of the 
patient and consideration of laboratory data and other factors unique to the patient. Standards in 
medicine change as new data become available.  
Drugs and dosages: 
When prescribing medications, the physician is advised to check the product information sheet 
accompanying each drug to verify conditions of use and to identify any changes in drug dosage schedule 
or contraindications. 

 
POLICY ON UNLABELED/OFF‐LABEL USE 
The Endocrine Society has determined that disclosure of unlabeled/off‐label or investigational use of 
commercial product(s) is informative for audiences and therefore requires this information to be 
disclosed to the learners at the beginning of the presentation. Uses of specific therapeutic agents, 
devices, and other products discussed in this educational activity may not be the same as those 
indicated in product labeling approved by the Food and Drug Administration (FDA). The Endocrine 
Society requires that any discussions of such “off‐label” use be based on scientific research that 
conforms to generally accepted standards of experimental design, data collection, and data analysis. 
Before recommending or prescribing any therapeutic agent or device, learners should review the 
complete prescribing information, including indications, contraindications, warnings, precautions, and 
adverse events. 
 

PRIVACY AND CONFIDENTIALITY STATEMENT 
The Endocrine Society will record learner's personal information as provided on CME evaluations to 
allow for issuance and tracking of CME certificates. The Endocrine Society may also track aggregate 
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and improvement of its CME program. No individual performance data or any other personal 
information collected from evaluations will be shared with third parties. 
 
ACKNOWLEDGEMENT OF COMMERCIAL SUPPORT 
This activity is supported by the in‐kind use of equipment from Esaote North America, Inc.; FNApath; GE 
Healthcare; and RGS Healthcare. 
 

AMA PRA CATEGORY 1 CREDIT™ (CME) AND ABIM MOC POINTS INFORMATION 
To receive a maximum of 8.5 AMA PRA Category 1 Credits™, participants must complete the activity 
evaluation form online at http://education.endocrine.org/ATUS2017 by Monday, May 1, 2017. After 
completing the evaluation, you will be able to save or print a CME certificate and, if you are eligible for 
MOC points, you will also be able to report 8.5 points to the ABIM. 
For questions about content or obtaining CME credit or reporting MOC points, please contact the 
Endocrine Society at http://education.endocrine.org/contact. 
   
UNDERSTANDING ULTRASOUND
PHYSICS TO OPTIMIZE IMAGING 
Lawrence Kim, MD 
PHYSICS AND PRINCIPLES
OF
THYROID/PARATHYROID
ULTRASOUND
 Overview

• Properties of Sound Waves in

Tissue
• Medical Ultrasound Devices
• Imaging and Artifacts
• Doppler
Compression

Rarefaction
Wavelength-frequency relationship

v=f
Sound Frequency

1 c/s = 1Hz
1,000 c/s = 1kHz
1,000,000 c/s = 1MHz
 THE SOUND SPECTRUM

20 20
Hz kHz

Infrasound Audible Sound Ultrasound

 Sound Velocity (m/s)

Air 340

Water 1500

Fat* 1470

Liver* 1540

Muscle* 1500-1600

Bone* 1900-3700
 Sound Intensity

• Measure of the amount of energy being transmitted

through a given area
• Expressed in Watts/m2
• Threshold of human hearing 1X10-12 W/m2
• Threshold of hearing defined as 0 dB
 Sound Intensity Decreases with Distance
from Source

• Inverse-square law 1 2 4

1.2
1
0.8 1/22 W/m2
0.6 1 W/m2 =1/4 W/m2
1/42 W/m2
0.4 =1/16 W/m2
0.2
0
1 2 3 4 5 6 7 8 9 10
 Acoustical Impedance

• Property of different tissues (medium)

• Differs by frequency
• Impedance = density X propagation speed (Z=pv)
• Differences in acoustical impedance cause reflection
 Wave Reflection and Acoustical
Impedence
• When 2 structures
of significantly
different acoustical
impedence form an
interface, the
interface becomes a
reflector sending
waves back to the
transducer
 Attenuation
• Sound pressure (signal amplitude) decreases as
wave travels through a medium
• Attenuation is due to viscosity of the medium
• Attenuation proportional to frequency () squared*
•  has been determined empirically for tissues

22
*Stokes’ Law: =
3V3
 Attenuation

Attenuation (dB) = (dB/cm) x d(cm)

Doubling the probe frequency

results in 4 X 

Therefore doubling probe frequency

results in 4 fold more attenuation per
unit distance
Attenuation causes weaker
echoes from distant objects

Distance
Time-Gain Compensation
of Attenuation

Distance
 Resolution

• Clarity of picture
• Ability of equipment to detect two
separate reflectors in tissue and to
display them as two separate reflectors
on the monitor without merging them
 Resolution
• Axial or Longitudinal Resolution-
distinguishes objects parallel or in line with
the beam
• Lateral Resolution- distinguishes objects
perpendicular to beam
Axial Resolution
 Focus and Lateral Resolution

Transducer

Beam

Fresnel zone

Focus Point

Fraunhofer zone
Focus and Lateral Resolution

Transducer

Beam

Focus Points
Focus and Lateral Resolution
 Characteristics of
Sound Frequency

Sound Sound Axial

Frequency Penetration Resolution

High

Low
 High Frequency Beam
Characteristics
• Resolution superior
• BUT, tissue absorption increases as frequency
increases
• 7.5 to 18 Mhz optimal for neck scanning
Medical Ultrasound Devices
 Piezoelectric Effect

Electric current

Mechanical Energy
 Piezoelectric Crystals

• Quartz naturally occurring

• Most medical U/S crystals synthetic
• Ferroelectrics- most common lead zirconate titanate
(PZT registered trade name)
Transducers
 Types of Transducer

• Sector Transducer
• Mechanical Transducer
• Array Transducer
Linear Array
 Array Transducer
Transducer

Sectors

Hundreds of sectors
typical
Ultrasound Waves Intermittent
• Allows receiving signals to be interpreted
• Pulse rate- number of separate packets of sound
transmitted, e.g. 1000 pulses/sec
• Transducer serves as receiver between pulses
 Phasing
Transducer

Active sectors

Diminishes artifacts -
Improves lateral resolution
Imaging and Artifacts
Echogenicity

Anechoic
Hypoechoic
Isoechoic
Hyperechoic
 Anechoic

Carotid Artery
Anechoic

Thyroid Cyst
Isoechoic
Isoechoic
 Hypoechoic

Parathyroid adenoma
Hyperechoic
Hyperechoic
 Image Artifacts
• Diagnostic vs. Misinterpretation
• Examples:
» Enhancement
» Shadowing
» Reverberation
» Refraction
» Reflection
» Comet Tail Artifact
Enhancement
Enhancement
Shadowing
Reverberation
Reverberation
Reverberation
Refraction/Edge-effect
Refraction

Incident Reflected
Beam Beam
Medium 1
Medium 2
Transmitted
Beam

Snell’s Law
Refraction / Edge-effect
Edge Effect
Reflection
Reflection
Comet Tail Artifact
Doppler
Doppler Equation

V = Df c
2 f cos q
 Doppler Curve
Peak systolic velocity

Area under curve = Power Flow

Figure adapted from Hirata et al, Stroke. 2006;37:2552-2556

 Power Flow Doppler
• Displays anatomy better than standard Doppler
• Uses fewer, shorter pulses to give a mean
frequency shift at each area of measurement.
Frequency shift displayed as a color pixel.
• The scanner builds the color image, which is
superimposed onto the B-mode image.
• The transducer elements are switched rapidly
between B-mode and color flow imaging to give
an impression of a combined simultaneous
image.
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/doppler/capitulos-html/chapter_01.htm
 Summary
• Sound waves move through tissues at varying
speeds
• Interfaces between different tissues produces echoes
• Medical ultrasound devices utilize the piezoelectric
effect and computer image generation
 Summary
• High frequency probes produce superior resolution
but poor penetration
• Relative echogenecity can be described as anechoic,
hypoechoic or hyperechoic
• Interfaces between tissues may produce artifacts
 Summary
• Doppler can be used to calculate speed of movement
• Power Doppler is useful for anatomic delineation of
blood vessels
NORMAL HEAD & NECK ULTRASOUND ANATOMY 
Jennifer A. Sipos, MD 
 Cervical Ultrasound
Normal Thyroid Findings

Jennifer Sipos, MD
Associate Professor
Division of Endocrinology
Director, Benign Thyroid Disorders Clinic
The Ohio State University, Wexner Medical Center
 Acknowledgements
Thank you to Dr. Robert Levine, Dr. Susan
Mandel, and AACE for the slides
 The Thyroid Gland
• Named after the Thyroid
Cartilage
(Greek: Shield-shaped)
• Wharton 1656: “glandulae
thyroidaeae” “whose
purpose is to….. beautify
the neck…. particularly in
females to whom for this
reason a larger gland has
been assigned”
Marie de Médici, Rubens 1622
 The Thyroid Gland
Embryology

• Originates as proliferation of endodermal epithelial

cells in pharyngeal floor at 4th week gestation
• Descends in front of pharyngeal gut through the
thyroglossal duct to migrate to the base of the neck
• During migration, it remains connected to the base
of the tongue by the thyroglossal duct
• HOWEVER, the connection is obliterated by 7-10
wks gestation
Neck Anatomy

• Derived from endodermal

tissue at base of tongue
• Embryonal remnants form
Thyroglossal duct; pyramidal
lobe; lingual thyroid
• Fuse with C-cells (neural
crest origin), derived from the
ultimobranchial body, of the
5th branchial arch
• C-cells scattered through
posterior/superior lobes
Sites of normal and
ectopic thyroid
Lingual
Intralingual
Sublingual
Thyroglossal Cyst
Thyroglossal Duct
Pyramidal Lobe
Normal Thyroid

Retrosternal
Thyroid Anatomy: anterior view
 Thyroid Anatomy: posterior view
Vagus nerve

Superior thyroid artery Superior laryngeal

nerve

Pharyngeal
constrictor
muscles

Superior
Superior
parathyroid
parathyroid

Inferior thyroid artery L

R

Recurrent
Laryngeal
nerves
 Thyroid Anatomy
Anterior view

Fibrous band
Omohyoid

Anterior Jugular Sternothyroid

Vein

Inferior Thyroid Vein

Look for superficial vessels
Less transducer pressure to confirm
 Thyroid Anatomy

• Each lobe has oval shape with rounded superior

pole and elongated inferior pole
• Lobe dimensions may vary greatly from 4-6cm
in length
• Usually the lobe thickness (AP dimension) is
less than 2cm
• Normal adult thyroid volume is 10-15cc
 Isthmus Sternohyoid muscle
Trachea
Sternocleidomastoid muscle Sternothyroid muscle
Omohyoid muscle

Internal jugular vein esophagus

Carotid artery Parathyroid gland

Longus colli muscle

 Normal Thyroid

Strap muscles Isthmus

Strap muscles SCM
SCM

Trachea
Jugular
Jugular
Carotid
Carotid

Esophagus
longus colli Iongus colli
Sagittal US Scan of Normal Thyroid

Superior
Inferior
 Echogenicity
• Normal thyroid is homogeneously hyperechoic
compared to the strap muscles
• Similar echogenicity to the submandibular
gland
• Nodule echogenicity is defined relative to the
normal thyroid
– Isoechoic
– Hyperechoic
– Hypoechoic Sensitivity 81%, Specificity 53%
– marked hypoechogenicity, defined as relative to
strap muscles1
1Kim et al, AJR 2002
Normal Thyroid Echogenicity

Sagittal View, Thyroid Submandibular Gland

 Thickness of the isthmus
• Isthmus normal transverse dimensions <3-4mm

• Transverse dimension >5mm is abnormal

• Assumes no nodules present in isthmus

3mm
9mm
 Pyramidal Lobe
• Embryonic remnant of
the thyroglossal duct
• Cadaveric prevalence
30-55%1
• Sonographic prevalence
15-20%1

1 Cengiz et al 2013 Mol Imaging Radionucl Ther 22: 32-35

 Pyramidal Lobe

Transverse View Sagittal View

 Tubercle of Zuckerkandl
• Variable size
• Adjacent to the
recurrent laryngeal
nerve and superior
parathyroid
• Originates from fourth
pharyngeal pouch
Tubercle of Zuckerkandl
 Tubercle of Zuckerkandl

C
Trachea
Transverse Spinous Processes

• Thyroid lies over

2nd and 3rd
tracheal rings
• Opposite the 5th,
6th, 7th cervical
vertebrae
Transverse Spinous Process
Measurement of Thyroid
Width and Depth

D
W
Measurement of Thyroid
Length
Thyroid Volume
Volume = (WxDxL)
 Normal Thyroid – Composite View

Strap SCM

CA R Lobe L Lobe
IJ Trach

LCM Esoph
 Transverse View – High Neck
Vocal Fold
Arytenoid Cartilage
 Transverse View – Mid Neck
Superior Thyroid Artery
Transverse View – Low Neck

Sternothyroid
Sternohyoid

Sternocleidomastoid

STM SHM SCM

RL LL
T IJV
CA
CA
Normal Thyroid – L Transverse

High

Mid

Low
Normal Thyroid – L Sagittal
Lateral

Mid

Medial
CHALLENGES IN SONOGRAPHIC ASSESSMENT OF 
THYROID NODULES 
Susan J. Mandel, MD, MPH 
   
Challenges in the Sonographic
Assessment of Thyroid Nodules

Endo 2017 Ultrasound Course

Susan J. Mandel, MD MPH

Professor of Medicine and Radiology
Perelman School of Medicine,
University of Pennsylvania
 Diagnostic thyroid ultrasound

Risk stratification

ATA Guidelines 2009, 2016; AACE/AME/ETA Guidelines 2010

 Topics for discussion

• Echogenicity
• Bright reflectors
• Margins
• Shape

Trees (individual features) then forest

(sonographic patterns) later . . .
 Echogenicity
• Normal thyroid is homogeneously
hyperechoic compared to the strap
muscles
• Nodule echogenicity is defined relative to
the normal thyroid (?Hashi’s background)
– Isoechoic/Hyperchoic grouped together
– Hypoechoic
– Sensitivity 81%, Specificity 53%
– Marked hypoechogenicity, defined as relative
to strap muscles1
1Kim et al, AJR 2002
Normal thyroid

trachea
 Hypoechoic nodules

Benign hyperplastic nodule Papillary carcinoma

• Most papillary cancers are hypoechoic
• However, since benign nodules are much more
common, most hypoechoic nodules are benign!
• The likelihood of a cancer increases if
hypoechogenicity is combined with a solid consistency,
calcifications and/or intranodular flow
 Hypoechoic nodules

Hypoechoic Markedly hypoechoic

c/w strap muscles
 Iso/Hyperechoic Nodules

Follicular carcinoma
Hyperplastic nodule
If associated with cystic spaces  hyperplastic
If uniformly solid or associated with an irregular
halo  concerning for a neoplasm such as
Follicular or Hurthle cell adenoma/carcinoma or
Follicular variant PTC
 Benign Hürthle PTC foll variant Follicular thyroid cancer
cell adenoma Could be NIFTP!

Hyperplastic nodule Hyperplastic nodule

20-30% of all cancers are Iso/hyperechoic:

predominantly follicular/ Hürthle cell
 Sonographic features:
Papillary vs. Follicular thyroid cancer
100
90
80
*
Frequency (%)

70
60 *
50
40 *
30
20
10
0
*
Hypoechoic Irregular Solid MicroCa2+
margins

Chan, J Ultrasound Med 2003; Yuan, Clin Imaging 2006; Jeh, Korean J Rad 2007
 Sonographic features:
Papillary vs. Follicular Variant of PTC
100 Classic PTC
FV PTC
Frequency (%)

80 *
60
*
40

20
* *
0
Hypoechoic Spiculated Smooth MicroCa2+
margins margins

Kim J Ultrasound Med 2009

 Partially cystic nodules—the solid part

Uniformly solid area, abutting one side of cyst

Kim Am J Neuroradiol 2010 31:1961
 Partially cystic nodules: what’s the
difference?
Solid components concentric concentric

• LOWER risk (ATA Very

low suspicion pattern):
Concentric
configuration with
blunt angles
• HIGHER risk (ATA Low
suspicion pattern):
Eccentric configuration eccentric eccentric
with acute angles
PEARL! Cystic papillary cancer solid
component is iso/hyperechoic and
rare time microcalcs not in
hypoechoic
Kim solid2010
Am J Neuroradiol area
31:1961
 Cystic Papillary Cancer
• <5% of PTC are >50% cystic
• Usually with frond-like regions and/or marked vascular
flow and calcifications

Comet tail
reverberation
artifact

Henrichsen J Clin Ultrasound 2010;38:361

Cystic Papillary Cancer
 Bright reflectors

• Calcifications
• Nonshadowing bright reflectors
 Calcifications
(present in about 30%)

• Macro calcifications: hyperechoic spots

with distal acoustic shadowing (drop out)
• Microcalcifications: hyperechoic spots
<1mm without acoustic shadowing
(thought to represent psammoma bodies)
Sensitivity 44%, Specificity 89%
 Calcifications
Microcalcifications Macro calcifications (peripheral)
(psammomatous) in papillary in follicular thyroid cancer
thyroid cancer

Trigiani Thyroid 2008;18:1017

Microcalcifications—the impact of
post acquisition image processing

Coarse
Ca2+
 Macrocalcifications
>2mm

• A=SOLITARY- linear or
A B
round, larger than
2mm, central
• B=SOLITARY-linear or
C D round, larger than
2mm, at margin
• C=CURVILINEAR-
greater than 1200 of
margin
• D= COARSE
Kim, J Ultrasound Med 2008; 27:1179
 Macrocalcifications

• Can occur in Hashimoto’s, need to confirm no

associated nodule
• Common in multinodular goiters secondary to
dystrophic deposition in regions of prior
hemorrhage/fibrosis
Khoo Arch Oto Head Neck Surg 2002;24:651
 Macrocalcifications

• Most concerning if associated with solid and

hypoechoic nodules and/or high risk features --
microcalcifications, taller than wide shape,
infiltrating margins

Khoo Arch Oto Head Neck Surg 2002;24:651

 Medullary Cancer
Hypoechoic, infiltrative borders with
coarse central calcification

Wolinski Endokrynologia Polska 2014;65:314

 Curvilinear (peripheral) calcification

Complete, regular
or “eggshell” Interrupted
with soft
tissue Papillary cancer
excrescence

Follicular cancer
More likely benign
Yoon J Ultrasound Med 2007; 26:1349; Park Yonsei Med J 2014;55:339; Kim J Ultrasound 2008;27:1425
 Curvilinear Calcification
Incomplete and irregular and/or subtle ST protrusions

Papillary cancer
Papillary cancer
1.3 cm PTC FV with eggshell calcifications
 ? Role of macrocalcifications

With the exception interrupted linear

calcifications, we DO NOT KNOW
whether macrocalcifications modify
malignancy risk based upon grey scale
imaging alone

Kim, J Ultrasound Med 2008; 27:1179; Lee Thyroid 2013;23:1106

? Coarse calcification

No dropout
Clumped Colloid

3 months earlier
Other nonshadowing
echogenic foci
 Echogenic foci with comet tail artifact

In pure cystic Can you

nodules, comet really tell
artifact indicates the
a benign cyst difference?

Comet tail artifacts

• Large (> 1 mm long) less
likely cancer (4%)
• Small (≤ 1 mm long) more
likely cancer (16%)
Mahli AJR 2014; 203:1310
Comet tail (short) and
microcalcifications
 More echogenic foci and comet tail

sagittal sagittal

???

Small hyperechoic linear streaks

just posterior to small cystic area:
posterior acoustic enhancement!
More echogenic foci and comet tail

Linear streak Comet tail (large)

Note triangular shape
 “Spongiform” nodules
• aggregation of multiple
microcystic components in
more than 50% of the
volume of the nodule
• “honeycomb of internal
cystic spaces”

<2% chance of malignancy

Moon Radiology 2008; 247: 762-70; Bonavita AJR 2009; 193:207-13
 Spongiform nodules
Mix of linear echogenic foci and comet tail
 Nonshadowing echogenic foci
and cancer risk--depends upon context
• Two large academic centers (UCLA and Brown)
• 950 nodules: 704 nodules with echogenic foci,
246 without
Low malignancy rate for partially cystic nodules

p<0.01

Mahli AJR 2014; 203:1310

 Nonshadowing echogenic foci
and cancer risk--depends upon context
• Two large academic centers (UCLA and Brown)
• 950 nodules: 704 nodules with echogenic foci,
246 without
Low malignancy rate for partially cystic nodules

p<0.01

Mahli AJR 2014; 203:1310

 Margins

• Well-defined and regular or smooth

• IRREGULAR--Infiltrative, spiculated, lobulated1
– Sensitivity 55%, Specificity 79%
– some malignant nodules have a predominately regular
border but are irregular in only small portion requiring
high-resolution technique
• Remember POORLY or ILL DEFINED is NOT
the same as DEFINED AND IRREGULAR

1Kim et al, AJR 2002

 What defines the margins of a nodule?
• Hypoechoic or sonolucent rim surrounding
ISO/HYPERechoic nodule (thought to
represent the compressed perinodular
vessels)—HALO
– Smooth and thin thought to represent
compressed perinodular blood vessels
– Thick or irregular—more suggestive of
CAPSULE of neoplasm (follicular or Hurthle
cell carcinoma or adenoma; encapsulated
papillary cancer)1

1Cerbone et al, Hormone Res 1999

 Smooth halo Thick, irregular halo
sagittal
sagittal

Thin halo is
compressed blood Follicular cancer
vessels
 What defines the margins of a nodule?
• Hypoechoic or sonolucent rim surrounding
ISO/HYPERechoic nodule (thought to
represent the compressed perinodular
vessels)—HALO
– Smooth and thin thought to represent
compressed perinodular blood vessels
– Thick or irregular—more suggestive of
CAPSULE of neoplasm (follicular or Hurthle
cell carcinoma or adenoma; encapsulated
papillary cancer)1
• Difference in echogenicity from
surrounding thyroid parenchyma, i.e.
HYPOechoic nodule c/w normal thyroid
1Cerbone et al, Hormone Res 1999
 Margins

Smooth Ill-defined

Microlobulated Lobular Spiculated Irregular/

Jagged
http://www.oncoprof.net/Generale2000/g04_Diagnostic/Mammographie/gb04_mm06.html
 Margins: differences in nodule’s
echogenicity

Spiculated Lobular
Papillary cancer Papillary cancer

Irregular/ Micro-
Jagged Papillary cancer lobulated

Anaplastic cancer
Pitfall of Infiltrating Margins

July 2015
6 x 7 x 9 mm
 Aug 2015

Dec 2015

Viral Thyroiditis
Elevated ESR
Margins: differences in nodule’s
echogenicity

Ill-defined

Margins ill-defined,
NOT DEFINED and INFILTRATIVE
Note interface between cyst
fluid and thyroid parenchyma is
better defined
 Margins—difference in nodule’s
echogenicity ILL DEFINED
Margins ill-defined,
NOT DEFINED and
INFILTRATIVE
Note interface between
cyst fluid and thyroid
parenchyma
SPONGIFORM
Larger spongiform nodules
Hyperplastic nodule
• Area of the thyroid with follicular
hyperplasia and accumulation of
colloid
• Composed of follicles of various
sizes and age, colloid, macrophages
Hyperplastic
nodule

HALO

Normal
thyroid
Extrathyroidal invasion: Invasion
through the capsule into muscle
Extrathyroidal invasion

Esophagus
 Invasion of capsule and
metastatic lymphadenopathy

CA

Sagittal left lobe Transverse left lateral neck

11 mm Papillary Thyroid Carcinoma

 Shape: taller (anterior/posterior)
than wide

• Nodule is taller than

wide on the
transverse view—
AP > transverse CA
Sensitivity 48%,
Specificity 92% trachea
2.5cm
1.6cm

Kim AJR 2002; Cappelli Clin Endocrinol 2005; Moon Radiology 2008
Taller than wide shape
 Taller than wide shape better
predictor of malignancy in
SMALLER but NOT larger nodules
Nodule size Sensitivity Specificity

0-0.5 cm 81.4 96.8

0.5-1.0cm 78.6 94.4

>1.0 cm 25 93.5

Ren J Ultrasound Med 2015; 34:19-26

Vascularity
 Patterns of nodular flow

sagittal sagittal

peripheral vascularity intranodular vascularity

 Vascularity of nodules in Korea
• Study of 1083 nodules comparing
vascularity as an independent
predicator of malignancy (96% PTC)
• “Vascularity itself or a combination of
vascularity and grayscale US features
was not as useful as the use of
suspicious gray-scale US features alone
for predicting thyroid.”
– Marked hypoechogenicity, ill-defined
margins, microcalcifications, taller than
wide
Moon Radiology 2010;255:260
 MULTIVARIABLE analyses of
sonographic features
Micro Hypo- Irreg Tall> Solid Vascu-
Ca2+ echoic margins wide larity

Frates
Cappelli
Nam-Goong

Gul High proportion of

Popowicz follicular cancers
Salmaslioglu

Papini
Kwak
Moon 2008
Moon 2010
Constellation of Sonographic
features

ULTRASOUND PATTERN
 ATA Nodule Sonographic Pattern Risk of Malignancy

High
Suspicion
70-90%

Intermediate
Suspicion
10-20%

Low
Suspicion
5-10%

Very low
Suspicion
<3%

Benign
<1%
ULTRASOUND INTERPRETATION OF                            
NON‐THYROID NECK PATHOLOGY 
Kevin T. Brumund, MD 
   
Ultrasound Interpretation of Non-Thyroid Neck
Pathology
Kevin T. Brumund, M.D., F.A.C.S.
Associate Professor of Surgery
Head and Neck Surgery
University of California, San Diego Health Sciences
VA Medical Center San Diego
Head and Neck Ultrasound
• Although utilized extensively to evaluate for thyroid and
parathyroid pathology, ultrasound is useful for evaluating
all masses within the head and neck, especially lymph
nodes
• Coincidental secondary pathology may be encountered
• Clinician performed ultrasound gives real-time information
to the examiner, allowing for immediate assessment and
possible intervention
• Useful for initial assessment of any neck mass as well as
for surveillance
• Can differentiate between benign and malignant pathology
Head and Neck Ultrasound
Superficial masses
• Sebaceous cyst and
epidermal inclusion
cyst
– Typically tethered to
overlying skin
– Course debris
– Posterior enhancement
Superficial masses
• Lipoma
– Superficial or deep
– Ovoid, hypoechoic mass
– Horizontal striations
– Physical exam + ultrasound
diagnostic
– FNA unnecessary
Salivary Glands
• Ranula
– Results from an obstructed
duct, often a sublingual
gland
– Presents as an
anterior/lateral sublingual
cystic swelling in the floor of
the mouth
– Becomes a plunging ranula
when it extends inferiorly and
posteriorly around the
mylohyoid into the
submandibular triangle
Salivary Glands
• Plunging ranula
– Extends into submandibular
triangle
– Cystic dilation adjacent to
SMG
Plunging Ranula
Salivary Glands
• Sialolithiasis
– Can see hyperechoic stone
in duct; posterior shadow
– Ductal dilation proximal to
calculus
Sialolithiasis
Salivary Glands
• Sjogren’s Syndrome
– Autoimmune disorder causing parotitis as a result of lymphocytic
infiltration of the parotid glands (lacrimal glands as well)
– Causes xerostomia and keratoconjunctivitis sicca
– Female predominance, often associated with rheumatoid arthritis
Salivary Glands
• Sjogren’s
– Xerostomia, parotid swelling
– Honeycombed appearance
of gland (note similar
appearance to Hashimoto’s
thyroiditis)
Salivary Glands
• Parotitis
– Often bacterial
– Swollen, inflamed, painful gland
– Purulence from Stensen’s duct
Salivary Glands
• Parotid cysts
– Seen in HIV
– Filled with proteinaceous
debris
Parotid cysts
Salivary Tumors
• Pleomorphic adenoma
– Hypoechoic, discrete but
irregular capsule, areas of
cystic degeneration,
posterior enhancement
– Avascular stroma/lack of
internal vascularity
Pleomorphic Adenoma
Mucoepidermoid Carcinoma

Note irregular borders

Central Neck
• Thyroglossal Duct Cyst
– Thyroid descends at 5 weeks
gestation from foramen cecum
at tongue base and completes
its final journey at 7 weeks
– Initially epithelial lined tube
persists and then obliterates.
When this does not occur, risk
of bacterial contamination and
infection
– Treatment requires removal of
central hyoid to prevent
recurrence
– WDTC rare but occurs
Central Neck
• Thyroglossal Duct Cyst
– Midline cystic mass
often superior and
anterior to hyoid bone;
occasionally displaced
laterally
– Filled with debris, even
colloid demonstrating
comet-tail artifact
Thyroglossal Duct Cyst
Thyroglossal Duct Cyst
Zenker’s Diverticulum
• A pseudodiverticulum
representing a herniation
through a weak area
between the inferior
constrictor muscle and the
cricopharyngeus muscle
• Symptoms include
dysphagia, regurgitation
of undigested food,
possible aspiration
Zenker’s Diverticulum
• Outpouching behind
thyroid lobe with
expanded esophageal
pattern
• Food debris, usually
sonorefractive, can be
identified and clears with
sequential swallows
Zenker’s Diverticulum
Zenker’s Diverticulum
Thymus
• Less echogenic than
normal thyroid
• Echogenic lines
representing connective
tissue septa (“speckled”
pattern)
• Hassall’s corpuscles of
thymus appear similar to
microcalcifications of PTC
Lateral Neck
• Carotid body tumor
– Paraganglioma at carotid
bifurcation
– Mass splays internal and
external carotid arteries
– Highly vascular
Carotid Body Tumor
Lateral Neck
• Schwannoma/neural
tumors
– Vagus, sympathetic chain,
cervical plexus
– Associated signs/symptoms
– Adjacent to great vessels,
usually displacing carotid
anteriorly
– Tapering at end of lesion
where nerve of origin noted
Schwannoma
Lateral Neck
• Traumatic neuroma
– Prior surgery
– Hypo-isoechoic mass
– Nerve enters mass
– Digital pressure producing
pain a supportive maneuver
in addition to ultrasound
– Avoid FNA
Lateral Neck
• Branchial cleft cyst
– One of the most
challenging, metastatic
cervical LAD often
misdiagnosed as a
branchial cleft cyst
– Usually a solitary cystic
structure with imperceptible
cyst wall
– Variable internal
echogenicity
– Posterior enhancement
common
Head and Neck Ultrasound
• Point of care clinician-performed ultrasound allows for
comprehensive exam of the entire neck (importance of
examining the neck when assessing a thyroid lesion and
examining the thyroid gland when assessing a neck mass)
• Utilize ultrasound to confirm previous imaging studies and
clarify/expand upon findings
• Immediate U/S guided FNA as indicated
• Surgical planning
• Surveillance
SONOGRAPHIC ASSESSMENT OF CERVICAL LYMPH NODES 
Peter J. Mazzaglia, MD 
 
   
Sonographic Assessment of the 
Cervical Lymph Nodes
Peter J Mazzaglia MD
Associate Professor of Surgery
Warren Alpert School of Medicine 
Brown University
 Likelihood of nodal involvement
• Incidence of nodal mets in PTC ranges from 
30—90%
– Many of these are micrometastases with little 
clinical significance
– Macrometastases which are visible on ultrasound 
or intra‐operatively do increase the risk of local 
recurrence
• MTC: 50%
• Anaplastic: 40%
 Who needs it and Why?
• Everyone undergoing evaluation of a thyroid 
nodule
• Everyone scheduled for thyroidectomy
• Recognition of cervical nodal metastases and 
operative resection is the most effective 
means of decreasing local recurrence
– Best for patient if this is done at time of 
thyroidectomy
 Cervical LN Assessment
• Anatomy‐‐surgeon performed
• ~5%‐‐25% of DTC will recur, usually in 1st 10 yrs
• Majority of recurrences in central or ipsilateral 
neck
• US twice as sensitive at detecting LN mets than 
radioiodine scan
• Central compartment
– < 50%
• Lateral compartment
– 85% 
 Detection of LN mets in 51 patients 
with neck recurrences

95%

45%

Frasoldati et al, Cancer 2003

 Modality of choice
• Ultrasound
– Best method for assessing nodal architecture
– Nodes and primary tumor can be simultaneously assessed
– Easily performed by endocrinologist or endocrine surgeon 
in the office
– Easily combined with FNA
• CT and MRI: more costly, not as accurate illustration of 
nodal architecture, but calcification can be seen
• I 123 and PET have significant numbers of false positive 
and negative results
Lymph Node Compartments and 
pattern of spread
• Level VI involved 1st
– Bordered by carotid 
laterally, hyoid 
superiorly, subclavian 
inferiorly

• Lateral compartments  
II—V follow
– Most commonly involves 
III and IV
Role of ultrasound in the management of patients with 
thyroid cancer
• Ability to detect non‐palpable local‐regional metastases 
and change surgical management
• Retrospective review of 212 patients
Group # with dz on
# of pts Percent
US, not on PE
Primary
107 21 20%
operation
Reoperation
for persistent 28 9 32%
disease
Reoperation
for recurrent 77 52 68%
thyroid ca
Total
212 82 39%
Kouvaraki et al. Role of preop ultrasonography in the surgical management of patients with thyroid 
cancer. Surgery 2003;134:946‐55.
 Cleveland Clinic Experience
• US assisted in formulating treatment plan in 2/3 of 
141patients with thyroid ca
– Identification of cervical lymphadenopathy pre‐op in 45 (31%)
• 19 in Central Compartment
• 26 in Lateral compartment confirmed by biopsy
– Confirmation of Ca recurrence when suspected by elevated Tg but 
neg. imaging in 10 (7) %
– Identification of thyroid ca in pts. referred for HPTH, 11 (8%)
– Identification of thyroid ca in pts. referred for neck masses that 
were identified as thyroid by US, 22 (16%)

Milas et. Al. Ultrasound for the Endocrine Surgeon. Surgery, Dec. 2005
 Surgeon performed US in the management of 
thyroid ca
• Review of all pts (72) undergoing neck surgery for thyroid 
ca since 2002
• US influenced mgmt in 41/72 (57%)
– Identification and FNA of 20 non‐palpable cancers
• 6 < 1 cm
– Identification of 27 contralateral nodules
• 14/27 positive for thyroid ca
• 4 patients had contralateral cancer missed by US
• Sens 82%, Spec 78%
– Identification of non‐palpable LN mets in 17/72 (24%)
• Sensitivity 59% in central compartment

Solorzano et al. Surgeon performed US in the management of thyroid malignancy. American Surgeon. 
July 2004
Rhode Island Hospital experience:
how surgeon‐performed ultrasound changes 
management
364 patients referred for thyroid disease

334 with outside ultrasound

64 (19.2%) findings on SPUS 270 (80.8%) findings

significantly differ from outside US consistent with outside study

58 (17.4%) had management altered 10 new nodules identified for biopsy

based on SPUS

28 (8.4%) patients referred for new or growing thyroid nodule 19 (5.7%) patients had non-palpable 7 nodules
did not meet criteria for biopsy enlarged cervical nodes suspicious for parathyroid adenomas

16 had no definite nodule or 13 patients had US guided lymph node FNA FNA for PTH performed
the nodule was < 1 cm 3 patients identified

12 patient's had US findings of Hashimoto's

without a definite nodule 3 patients diagnosed with metastatic
papillary thyroid cancer

In 6 patients the lymph nodes had a benign appearance

and biopsy not performed
Notable findings of other investigators
• Kouvaraki et al. Role of preop ultrasonography in the surgical 
management of patients with thyroid cancer. Surgery 
2003;134:946‐55.
– 39% of patients undergoing surgery  for thyroid cancer had non‐palpable 
metastatic disease detected only by ultrasound

• Solorzano et al. Surgeon performed US in the management of 
thyroid malignancy. American Surgeon. July 2004
– US influenced mgmt in 41/72 (57%)

• Milas et. Al. Ultrasound for the Endocrine Surgeon. Surgery, Dec. 
2005
– US assisted in formulating treatment plan in 2/3 of 141patients with 
thyroid ca
• Identification of cervical lymphadenopathy pre‐op in 45 (31%): 19 in Central 
Compartment and 26 in lateral compartment, confirmed by biopsy
ANATOMIC CHARACTERISTICS OF 
BENIGN AND MALIGNANT NODES
 Normal lymph node anatomy
• Cortex
• Medulla
• Fatty white hilum
– Contains
• Artery
• Vein
• Efferent lymphatics
 Size
• Most normal LNs are < 1  • Malignant
cm  – Average 6—7 mm
• BUT….nodes in the  – Up to 3 cm
neighborhood of the 
salivary glands, especially 
submandibular nodes can 
be much larger.  They are 
recognized as benign by 
the conservation of 
normal shape and 
echogenic features
 Shape
• Benign • Malignant
– Oval – Spherical
– reniform – Short to long axis ratio < 
0.5
 Nodal border
• Benign • Malignant
– Regular – Irregular
– Well‐defined margin – Poorly defined margin
 Hilum
• Echogenic hilus
– Characteristic of normal 
lymph node
– Present in 85%
– Site of nodal artery and 
vein, as well as efferent 
lymphatic vessel
 Echogenicity
• Normal  • Metastatic
– Hypoechoic relative to  – Hyperechoic (90%)
adjacent tissue
 Calcification
• May be present in 
metastatic nodes, 
especially PTC (50—
79%)
• Punctate, 
microcalcifications
• Peripherally located
 Cystic necrosis
• Benign • Malignant
– Not present – 20%
– Usually partial, but may 
be complete
 Vascular pattern
• Normal: hilar • Metastatic: peripheral 
vascularity or mixed vascularity
 Method of scanning
• Begin with a full thyroid ultrasound
• Assess central compartment, especially 
posterior and inferior to thyroid
– Look behind sternal notch and clavicle
• Assess lateral compartments
– Scan over carotid and jugular from submandibular 
gland to clavicle bilaterally (levels II—IV)
– Scan posterior to SCM (level V)
 Normal exam of the lateral cervical 
compartment levels II‐‐IV
• Examine from the 
submandibular region 
to the clavicle
• Keep carotid and 
jugular centered
 Hashimoto’s

• Central compartment 
adenopathy is common

• Nodes can range widely in 
size

• Often descend into upper 
mediastinum 
 Reactive lymphadenopathy

• 37 yo 1 yr s/p total 

thyroidectomy for 1.7 cm 
follicular thyroid ca.  Tg
undetectable

• US shows reactive 
lymphadenopathy without 
overly suspicious features
 Reactive lymphadenopathy
• January 10, 2017 • February 28, 2017
 Lymph node metastases from PTC
• Hyperechoic
• Microcalcifications
• Enlarged
• Well defined border
• Deforming internal 
jugular
 Large metastatic PTC nodes on 
ultrasound, color flow doppler and CT
 Surgical specimen
left modified neck dissection
• Lymph node levels II‐‐V

II

III

IV V
PTC lymph node metastases with 
calcifications
27 yo M s/p total thyroidectomy and left neck dissection at outside institution 
8 years ago, now presents with Tg of 41 and TSH > 150

Level II node posterior to 
submandibular gland Level IV lymph node
 Metastatic lymphadenopathy
• US highly sensitive
• LN mets as small as 3 
mm detectable
• Look for spherical shape 
and hypoechogenicity
Central compartment LN mets from PTC
Left lobe and left level VI Right lobe with PTC and right 
level VI node
 Cystic LN Metastasis
• 40 yo F s/p total thyroidectomy and central 
compartment dissection, with Tg of 5
 Submandibular lymphadenopathy
• Extremely common
• Frequently over 1 cm, 
can be close to 2 cm
• Retain oval shape and 
fatty white hilum
 Ultrasound guided LN FNA
• Important to align yourself, needle, 
target and ultrasound screen

• Only one skin stick required with 
several passes into the lymph node

• Suspend aspirate in cytolyte

• No local anesthesia necessary
ULTRASOUND OF THE VOCAL CORDS 
Denise M. Carneiro‐Pla, MD 
   
 Advanced Hands-on Thyroid
Ultrasound Workshop

Ultrasound of the Vocal Cords

Denise Carneiro-Pla, MD, FACS

Nothing to Disclose
 Objectives

 Recognize the usefulness of Vocal Cord

Ultrasonography (VCUS)

 Identify VC anatomy on ultrasound

 Understand the data available on this technique

 Use the steps and tips given to improve VC

visualization
 Recurrent laryngeal nerve injury during
cervical procedures leading to true vocal
cord (TVC) paralysis is infrequent

 Identification of TVC paralysis before cervical

re-exploration is critical: risk of bilateral vocal
cord paralysis and tracheostomy
 VC paralysis can be clinically not evident
when VC is paralyzed in the midline

 ALL patients with previous neck operations

or suspicious to have VC dysfunction
require vocal cord mobility evaluation
before neck re-exploration

 However, some surgeons are not as selective

recommending VC visualization to ALL
patients before and after any neck exploration
 Most surgeons would recommend vocal cord
function evaluation only selectively

 Any previous cervical procedures (cervical

fusion, carotid endarterectomy, thyroid and
parathyroidectomy)

 Massive goiters

 Intrathoracic goiters

 Hoarseness

 Suspicion of recurrent laryngeal nerve invasion

 Flexible laryngoscopy is the gold standard
study to evaluate vocal cord mobility

 Transcutaneous Vocal Cord Ultrasonography

has been shown useful and accurate in
demonstrating the vocal mobility in most
patients

 This convenient technique can be an asset for

surgeons and endocrinologists who perform US
routinely during cervical evaluation
 As expected, it is operator dependent with rate
of visualization >80% and >90% in females

 Age (older), gender (males), presence thyroid

cartilage calcification, and distance between
the skin and VC are limiting factors for VC
visualization
 Some studies have shown that VCUS can
demonstrate VC paresis. However, recent
report have shown that 33% of these
predictions were incorrect

 When compared to flexible laryngoscopy,

sensitivity of TVC paralysis identification
with VCUS is variable ranging from 62-93%
 Larynx Anatomy

Thyroid cartilage
Scanning angle

Cricoid cartilage
Thyroid Cartilage

Arytenoids
True vocal
cords
Positioning and Material

 Cervical hyperextension

 US probe with capability to decrease

frequency (8-9MHz)

 Ultrasound Gel
Technique for true vocal cord US

 Place probe anterior or just inferior to

the thyroid cartilage occasionally
angling it superiorly

 Decrease frequency to 8-9 MHz

 Increase gain
Visualization of structures

 True vocal cords

TC

 Thyroid cartilage
FC FC

 False vocal cords ARYT ARYT

 Arytenoid cartilage
Probe frequency 8-9 MHz

15 MHz
12 MHz

9 MHz
8 MHz
Normal Vocal Cord
Mobility
R L
True vocal
cords

False False
cord cord

Arytenoids
R L
TVC adduction
Valsalva maneuver

Valsalva Breathing

TVC abduction
When takes a breath
Orientation of flexible laryngoscopy and VC ultrasound

Post

R L

Post Ant
Ant
Ant

R L

Post
R Arytenoids L

TVC TVC

False False
R True vocal
L
cord cord cords

False False
cord cord

Arytenoids
Right True Vocal Cord
Paralysis
 Right
Paralyzed Left TVC
TVC and compensation
Arytenoid

Arytenoids asymmetry
Left True Vocal Cord
Paralysis
 Right TVC Paralyzed
compensation left TVC

Arytenoids asymmetry
Thyroid cartilage calcification

preventing
visualization
of TVC
 35th Annual Meeting
American Association of Endocrine Surgeons

Feasibility of surgeon-performed
transcutaneous vocal cord ultrasonography
in identifying vocal cord mobility:
a multi-institutional experience
Carneiro-Pla D, Miller BS, Wilhelm S, Milas M, Gauger PG,
Cohen MS, Hughes DT, and Solorzano CC
 Results

 510 pts from 5 institutions (8 surgeons)

were evaluated before and after neck
exploration
 Bilateral TVC visualization on US was
possible in 74% patients or in 77% of all
TVCUS

 TVC visualization was more common in

women (83%) than in men (17%) (p < 0.0005)
 Results

 TVC visualization was more common in

pts without thyroid cartilage calcification
(TCC) (81%) than pts with TCC (42%)
(p < 0.0005)

70 patients who had bilateral TVC

visualization by TVCUS and also had a DL
were compared, TVCUS correctly
identified all 7 paralyzed TVC
 36th Annual Meeting
American Association of Endocrine Surgeons

Impact of vocal cord

ultrasonography on endocrine
surgery practices
Carneiro-Pla D, Solorzano CC, and Wilhelm SM
 Methods
194 patients from 3 institutions who
had indication for FL were evaluated
before neck exploration

All patients had VCUS performed

during the initial surgical visit by one
of the 3 endocrine surgeons who are
certified in cervical US
 Conclusion
VCUS significantly changed these

surgical practices by avoiding

unnecessary procedures and

consultations in 76% of the patients

consequently reducing costs

 Pearls and pitfalls of transcutaneous VC US
 Requires decrease frequency and increase
gain

 Often not successful in visualizing VC in men

 Thyroid cartilage calcification prevent VC

visualization

 Requires some US skills but easily learned

 It is not very accurate in identifying decreased

VC mobility
 Pearls and pitfalls of transcutaneous VC US
 VCUS is easily tolerated
 Does not require additional instrumentation
or appointment with other specialist
 No extra charges since it is part of the
cervical US
 VC visualization during phonation and passive
breathing may take longer since it is subtle
with passive breathing and with phonation,
vibration artifact may make more difficult to
visualize the TVC
 Flexible laryngoscopy remains the gold
standard study to evaluate vocal cord mobility

 Transcutaneous Vocal Cord Ultrasonography is

accurate in predicting VC paralysis in most
patients, especially in females

 True vocal cord ultrasonography can be a great

asset to surgeons and endocrinologists
performing cervical US routinely. This technique
can potentially prevent FL in most patients
The best description of vocal cord findings in
this laryngeal ultrasound is?

1. Immobile right vocal cord

2. Immobile left vocal cord
3. Paresis right vocal cord
4. Paresis left vocal cord
5. Normal motion of both vocal cords
6. Suboptimal for interpretation
ULTRASONOGRAPHY FOR PARATHYROID LOCALIZATION 
Carmen C. Solorzano, MD 
   
Ultrasonography 
for Parathyroid 
Localization 
Carmen C Solórzano, MD, FACS
Professor of Surgery
Chief, Division of Surgical Oncology
and Endocrine Surgery
Vanderbilt University Medical Center
 Facts
• Concomitant thyroid disease is present in
approximately 2/3 of patients undergoing
parathyroidectomy

• US can accurately localize the abnormal

parathyroid (76-89%) and help operative
planning

• Ultrasound is the cheapest localization study-

when clearly positive you may go directly to
parathyroidectomy
On cost effectiveness: Wang TS Surgery 2011, Lubitz Ann Surg Onc 2012 
On US to localize: Milas Thyroid 2005, Solorzano JACS 2006, Van Husen WJS 2004, Solorzano Am Sug 2005, Jabiev Surgery 2009, 
Untch JACS 2011, Adler JACS 2010, Deutmeyer Surgery 2011
 Why Ultrasound in 
Hyperparathyroidism?
• Augments your physical exam
• Can diagnose and characterize thyroid nodules
to determine the need for FNA ahead of surgery
• Screen for vocal fold mobility
• Locate the parathyroid and guide operative
planning
• Determine cervical ectopic parathyroid locations
(intra-thyroid, carotid sheath, undescended)
• Save money, convenient and no radiation
 Thyroid US: Don’t Get 
Confused by Normal Anatomy
 Transcutaneous 
Vocal Cord Ultrasound

Right Left

Video
 Paralyzed Right Vocal Cord

Right Left

Video
 To be a Successful 
Parathyroid 
Ultrasonographer:

Knowledge of Anatomy
Knowledge of Embryology
Practice Practice Practice
 Embryology
• Upper glands from 4th branchial pouch and move
with the lateral thyroid lobe
• Lower glands from the 3rd pouch and move with the
thymus
• This helps you look for the parathyroid in ectopic
locations: Thymus, undescended, mediastinum,
thyroid, retropharyngeal or paraesophageal
Ectopic Locations

Yeh UCLA

Lee et al Oto Head and Neck Surg 2012
 Parathyroid
Anatomy 
• Superior parathyroids are usually posteriorly located
• Inferior parathyroids are usually anteriorly located

Longitudinal view right lobe

Perrier WJS 33:412, 20, 2009
 Appearance of Abnormal Parathyroids
Typical Atypical

Solid, hypoechoic Cystic areas, isoechoic

Homogenous Heterogenous

Smooth well defined borders Infiltrative or irregular borders

Oblong, tear drop, or oval Lobulated

shaped

Not calcified Calcified

Polar artery on Doppler Highly vascular on Doppler

Single Multiple

Located along the margins of Ectopic locations: retro-

the thyroid gland esophagus, high in the neck

above the thyroid, in the

thymic tongue, deep in the

mediastinum, in the thyroid

 Possible Locations of the 
Superior Parathyroid
• >90% posterior to the upper thyroid lobe near crico-
thyroid cartilage junction

• 4% posterior to the mid-thyroid lobe

• 3% superior to the thyroid lobe
• 1% retropharyngeal and retro-esophageal
• 0.2% intra-thyroidal
Superior Parathyroid
Longitudinal View

Longitudinal view 

Transverse view  Longitudinal view 
Superior Gland on Sestamibi
Intra‐Thyroidal Parathyroid: 
The Ultrasound Advantage

Longitudinal view 
Transverse view 
 Superior Parathyroid 
Cephalad to the Thyroid Lobe 

Longitudinal view 

Transverse view 
 Superior Parathyroid 
Cephalad Thyroid Lobe

Video
 Cystic and Solid 
Superior Parathyroid

Longitudinal view 
Transverse view 

Not to be confused with a thyroid cyst!
Sestamibi Negative
How can I use this 
Information?
 Superior Gland
Posterior to Mid Lobe

Video transverse view 
superior gland
Longitudinal view superior gland
Superior Parathyroid by 
Esophagus
Multiple Parathyroids
in Renal Failure
Longitudinal left Transverse Right
 Calcified Parathyroid 
Renal Failure on Sensipar

Long view Left
Possible Locations of the 
Inferior Parathyroid
• 69% caudal, posterior or lateral to the lower
thyroid pole

• 26% thyro-thymic

• Other: undescended, intra-thyroidal,

mediastinum thymus or mediastinum outside
of thymus
Inferior Parathyroid
Transverse View
“Wedge”

Note :
Anterior location
level of the trachea
caudal to the
thyroid lobe
 Inferior Parathyoid:
Longitudinal View 
The Thyroid Points to It

Longitudinal view of a 2cm enlarged parathyroid
 Inferior Parathyroid
Lateral to the Lower Pole of 
the Thyroid
 Something Inferior
Surgeon Explores…No Preoperative US
 Patient has a Failed 
Operation
Ultrasound Advantage
video

Transverse view of a large cystic and solid inferior parathyroid
CT Parathyroid Protocol (4DCT) 
Obtained in this Re‐op Patient 
 Inferior Parathyroid
Posterior to Lower Pole
Polar Artery, Arc, or Rim of Vascularity
Arc of Vascularity
 Longitudinal View 
Inferior Parathyroid
video
atypical
 Transverse
Inferior Parathyroid video
atypical
Tucked Under the Lobe
Video Right Inferior Long View
video
 Not in the Usual Location?
Look Elsewhere!
• Intra-thyroidal or partially intra-thyroidal
• Superior gland above the thyroid lobe
• Superior gland that has grown to occupy a
low in the neck- next to esophagus posterior
to the inferior thyroid artery-location
• Thymic or thyro-thymic: look under the
clavicle by angling the US probe
• Undescended inferior gland look high in the
neck near carotid bi-furcation
• Carotid sheath
 Other Ultrasound Uses
• Guides the surgeon to the exact spot
• Helps lateralize the parathyroid by guiding jugular
sampling for PTH measurement
• Helps identify/localize and mark the location of
transplanted parathyroid tissue for operative
planning
• To guide FNA of the parathyroid- not
recommended
 What about FNA of the 
Parathyroid
• Avoid
• Causes a reaction making the surgery difficult
• Pathologist may have a hard time distinguishing
between benign and malignant
• Could be useful in re-operative cases- but last resort
• Sometimes the parathyroid is confused with thyroid
and undergoes biopsy: cytology often time it’s a
follicular neoplasm

Wilhelm et al. JAMA Surgery 2016
AAES guidelines for the definitive management of HPT
 MEN1 Patient 
Left Forearm Transplant

Video
Prior Total Thyroidectomy 
Beware!
4DCT 
Shows a retropharyngeal
location but no thyroid
to compare to?

Sestamibi scan read as
negative

US can’t see

Explore: Turns out to be
thyroid tissue, one normal
parathyroid found in the
right neck not removed
 Prior Total 
Thyroidectomy‐ Later…
 Prior Total 
Thyroidectomy and HPT

L Sternocleidomastoid muscle
 Parathyroid US Pearls
• Use compression to increase visibility
• Look for the polar artery and arc of vascularity
• Always look for “ectopic” locations even when you
think you found the parathyroid
• Beware of the inferior parathyroid “tucked” under
the thyroid lobe
• Don’t be distracted by a large parathyroid
continue your exam…you may find another one
• When the patient gives a history of prior
thyroid/parathyroid procedures always look at the
SCM for an implanted parathyroid
 US Problems
• Body habitus- large BMI and thick short
necks
• Posterior location of the parathyroid gland
particularly in males
• Enlarged thyroids
• Hashimotos thyroiditis and associated
reactive adenopathy (confusing)
• Operator dependent
 My Algorithm:
Ultrasound in my clinic

Clearly positive US Negative or Equivocal US

Parathyroidectomy Sestamibi Scan
Focused or BNE Or 4DCT
with PTH guidance

Positive
Negative

Focused or BNE 
Solorzano JACS 2006 BNE with PTH
Solorzano and Carneiro‐Pla
with PTH
Surg Clin North Am 2014 guidance guidance
USE OF ULTRASOUND FOR                                      
THYROID CANCER SURGICAL PLANNING 
Scott M. Wilhelm, MD 
 
Use of Ultrasound for Thyroid
Cancer Surgical Planning

Scott M. Wilhelm, MD, FACS

Associate Professor and Section Head Endocrine Surgery
University Hospitals-Cleveland Medical Center
Cleveland, OH
Disclosures

• I have no disclosures

2
Easy Button
• Normal Head and Neck anatomy
• U/S Cervical Lymph nodes
• Vocal Cord U/S

3
Use of Ultrasound for Thyroid Cancer Surgical Planning
• ATA Guidelines- role and use of U/S
• Extent of Thyroid Surgery
• Discussion with patient/Expectations
• Reoperative Thyroid Surgery

4
ATA Guidelines

• 2015 American Thyroid Association Management Guidelines for Adult 
Patients with Thyroid Nodules and Differentiated Thyroid Cancer  
(THYROID- Volume 26, Number 1, 2016)
– A8/R6-Thyroid Sonography
– A9/R7- U/S for FNA
– A10/R8- Recommendations for diagnostic FNA of a thyroid nodule based on
sonographic pattern
– B4/R32- Neck imaging-U/S
– B34- Potential role of postoperative US in conjunction with postoperative serum
Tg in clinical decision-making
– C9+10/R65- What is the role of US and other imaging techniques during follow-
up?

5
 – ATA- Thyroid Sonography

• A8/R6-“Thyroid sonography with survey of the cervical lymph

nodes should be performed in all patients with known or
suspected thyroid nodules.”
• A9/R7- “US for FNA decision-making; FNA is the procedure of
choice in the evaluation of thyroid nodules, when clinically
indicated.”
• A10/R8- “Recommendations for diagnostic FNA of a thyroid
nodule based on sonographic pattern”.

6
How do ATA R6-8 help with preop planning?

• These guidelines mainly dictate the initial evaluation of a thyroid

nodule +/- FNABx
• However, we can use R8 features of thyroid nodules to aid in
operative planning and patient expectations/discussions.

7
Case 1

• 55y/o WF, PMHx: Stage III Rectal CA s/p resection , chemotx,

pelvic XRT
• Chest CT scan – “1.5cm mass R thyroid smooth borders, likely
benign”

8
Case 1

• Office U/S- 1.7x1.2 cm heterogeneous nodule, solid tumor,

irregular borders.

9
Case 1

• Planned Total Thyroidectomy based on expected ETE as seen on

preop U/S
• Discussed pt would likely need RAI for ETE.
• At surgery ETE into overlying Sternothryoid musculature was
found and resected en bloc. Final path did show ETE but
negative surgical margin.
• Pt did receive RAI but was already prepared for this idea.

10
Case 2

• 81 y/o AAF, presented to OSH with weakness and not feeling

well. Calcium level 14, iPTH 185. Acutely treated with IVF,
diuretics and bisphosphonates. Ca 10.9. Sestamibi c/w L inferior
adenoma. Referred for surgery.

11
 The American Association of Endocrine
Surgeons (AAES) Guidelines for the Definitive
Management of PHPT.

Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY,
Doherty GM, Herrera MF, Pasieka JL, Perrier ND, Silverberg SJ,
Solórzano CC, Sturgeon C, Tublin ME, Udelsman R, Carty SE.

http://archsurg.jamanetwork.com/article.aspx?articleid=2542667

12
Cervical U/S for primary hyperparathyroidism

• Recommendation 4-3: Cervical ultrasonography is

recommended to localize parathyroid disease and assess for
concomitant thyroid disease (strong recommendation; low-quality
evidence).

13
Case 2

14
Case 2

15
Case 2

• FNABx revealed PTC

• Planned Total thyroidectomy and parathyroidectomy
U/S – also shows invasion to
cricothyroid muscle.

16
Case 2

• Preoperatively, I counselled her about likely ETE

• Likely need for RAI
• Despite normal preop VC U/S, I was quite concerned about
proximity of her nerve to the tumor for postop hoarseness

17
Case 2 postop

• Tumor aggressively adherent to cricothyroid muscle which was

resected
• RLN dissected off tumor x 2.5 cm and into the CT muscle
• Path- +ETE, microscopic + margin
• Will get RAI
• + hoarseness, nerve palsy-did vocal fold injection with Restylane.
• Pt was aware of all of these possibilities which helped her Postop

18
Preoperative U/S for primary HPT
• Arciero et al. Preoperative Thyroid Ultrasound Is Indicated in Patients
Undergoing Parathyroidectomy for Primary Hyperparathyroidism. J Cancer
3:1-6, 2009. Eisenhower Army Med. Center
• 94 pts with pHPT
– 57% had concomitant thyroid nodule
– 56% of those required FNABx
– 17% of pts underwent combined PTX and thyroidectomy
– 6% risk of thyroid cancer in their pHPT pts.

19
U/S and Extent of thyroid surgery

• A8/R6-“Thyroid sonography with survey of the cervical lymph

nodes should be performed in all patients with known or
suspected thyroid nodules.”
• Multinodular goiter

20
MNG and thyroid cancer

• Frates et al- JCEM 91 (9): 3411-17, 2006. Harvard

• 1985 pts underwent bx of 3483 nodules
– Prevalence of thyroid cancer for solitary nodule vs MNG (14.8 vs 14.9%)
– Pts with MNG with nodules > 1 cm, 46% had Multifocal PTC, the cancer
was the largest nodule 72% of the time.
– Thus bx of only the largest nodule could miss cancer 30% of the time.
– They did not see a decrease in risk of cancer until at least 4 nodules were
biopsied.

21
MNG and thyroid cancer

• U/S can reveal additional non-palpable lesions of concern

• U/S can be used FNABx of the non-palpable lesions
• This may alter operative procedure from lobectomy to total
thyroidectomy and prevent reoperative procedures.

• Luo et al- Are there predictors of malignancy in patients with multinodular

goiters? J Surg Res 174: 207-210, 2011. Univ of Wisconsin

22
Intermission

“Is it time for lunch?” This is how full my brain is right now.

23
ATA Guidelines

• B4/R32- Neck imaging-U/S

– (A) Preoperative neck US for cervical (central and especially lateral neck
compartments) lymph nodes is recommended for all patients undergoing
thyroidectomy for malignant or suspicious for malignancy cytologic or
molecular findings. Strong recommendation, Moderate-quality evidence)

– (B) US-guided FNA of sonographically suspicious lymph nodes > 8–10mm

in the smallest diameter should be performed to confirm malignancy if this
would change management. (Strong recommendation, Moderate-quality
evidence)

24
B4/R32- Neck imaging-U/S

• Grebe SK, Hay ID 1996 Thyroid cancer nodal metastases:

biologic significance and therapeutic considerations. Surg Oncol
Clin N Am 5:43–63.

– Risk of nodal metastases in patients with PTC is approximately 30-50%

– Most common areas are Level VI,III, and IV.
– All areas can be assessed with U/S preoperatively.

25
Preoperative Lymph node assessment

26
Preoperative Lymph node assessment

• Overall Accuracy of U/S detecting malignant LN (PTC) is >70%.

– Parks et al- Performance of preoperative sonographic staging of PTC
based on the 6th ed. Of the AJCC/UICC TNM classification system. AJR
192:66-72, 2009.
• Identifying metastatic LN in PTC preop can alter surgical
planning in 20-30% of cases.
– Solorzano et al-Surgeon Performed U/S in the management of thyroid
malignancy. Am Surg 70:576-580, 2004.

27
Reoperative surgery

• U/S may also assist in localizing areas of concern preop to help

with intraoperative dissection.
– Sippel et al. Localization of recurrent cancer using intraoperative u/s
guided dye injection. World J Surg 33:434-39, 2009.
– Kang et al. Preoperative u/s guided tattooing localization of recurrences
after thyroid cancer.

28
Case 3

• 37 y/o woman who in 2015 underwent Total Tx with central neck

and left modified radical lymph node dissection.
• 7/11 lateral nodes + PTC.
• Now presents with rising TG, negative RAI scan.
• U/S- recurrent L lateral neck compartment LN, 8 mm, non-
palpable. Bx proven PTC.

29
Reoperative surgery

30
Vocal Cord assessment in thyroid cancer

• ATA- B12- Preoperative voice assessment (Recc 41- Preop

laryngeal exam should be done in all patients with)
– Preop voice abnormality
– History of cervical or upper chest surgery
– Known thyroid cancer with posterior extrathyroidal extension or extensive
central nodal metastases.

31
Translaryngeal vocal cord u/s

32
Summary- Use of Ultrasound for Thyroid Cancer
Surgical Planning
• ATA Guidelines- role and use of U/S
• Extent of Thyroid Surgery
• Discussion with patient/Expectations
• Reoperative Thyroid Surgery
– Localization
– Preoperative Laryngeal assessment

33
U/S- Just Do It!

34