An outline of an US examination is provided below:

1. The thyroid as a whole

• Location (typical, dystopia, ectopia)
• Dimensions and volume (also in comparison with the norm)
• Margins (regular/irregular, accurate/indistinct)
• Shape (typical; congenital anomalies: lobed constitution, aplasia, hypoplasia;
goiter)
• Echodensity (normal, increase, decrease)
• Echostructure (homogeneous, heterogeneous)
• Elasticity
• Blood vessels of the thyroid parenchyma (intensity, symmetry)
2. Thyroid abnormalities
• Character of changes (diffuse, focal, mixed)
• Location (in lobes and segments)
• Number of lesions
• Margins of lesions (regular/irregular, accurate/indistinct)
• Lesions size (in three mutually perpendicular planes)
• Echodensity, echostructure of lesions
• Elasticity of lesions
• Vascularity of lesions
3. Mutual relations of the thyroid with the surrounding structures
4. The status of regional lymph nodes

Vascularity
 1. Avascular. No blood low is detected within the lesion
2. Peripheral (perinodular). Blood low is mainly registered at the periphery of the
lesion, often in the shape of a rim.
3. Central (intranodular). Single or multiple vessels are detected within the thyroid
lesion without any peripheral rim-like low.
4. Mixed. Vascularization in both peripheral and central aspects of the lesion.

1. Hypervascular lesions show increased blood low, which often can be registered
as a peripheral rim and multiple arterial and venous vessels within the lesion,
representing a “color crown” sign.
2. Nodules with a medium degree of vascularization have the same intensity of
blood low as the thyroid parenchyma.
3. Hypovascular nodules demonstrate poor vascularization as compared with the
surrounding parenchyma.
4. Avascular nodules have no inner color spots and no peripheral rim

All thyroid abnormalities that can be detected sonographically are divided into dif-
fuse, nodular, and combined changes.
Diffuse changes confer the following principle pathologies:
• Diffuse nontoxic goiter (diffuse hyperplasia)
• Diffuse toxic goiter (Graves’ disease)
• Thyroiditis
Grayscale US reveals normal structure of thyroid tissue, which looks uniform,
homogeneous, and isoechoic (Fig. 4.1). Doppler modalities in diffuse nontoxic goi-
ter do not add any signiicant data to that afforded by grayscale sonography. The
intensity of color pattern and distribution of vessels do not differ from the norm
(Fig. 4.3). Diffusely enlarged thyroid in nontoxic goiter is of medium stiffness with
compression elastography that is identical to normal thyroid parenchyma. The color
pattern is regular, uniform, and symmetric (Fig. 4.4a). Normal stiffness in diffuse
thyroid hyperplasia is conirmed by quantitative measurements of share-wave elas-
tography (Fig. 4.4b). The Young’s modulus ranges from 10 kPa to 40 kPa with usual
igures of 12–23 kPa. CEUS is not applied for diagnosis of diffuse goiter.
The Example US Report in Diffuse Thyroid Hyp
ormal stiffness in diffuse
thyroid hyperplasia is conirmed by quantitative measurements of share-wave elas-
tography (Fig. 4.4b). The Young’s modulus ranges from 10 kPa to 40 kPa with usual
igures of 12–23 kPa.

CDI and PDI may reveal a negligible symmetric increase in the number of ves-
sels within thyroid lobes with a uniform distribution. A normal color pattern is
usually observed (Fig. 4.3).
• Compression elastography demonstrates medium strain with uniform and sym-
metrical pattern.
• Share-wave elastography reveals Young’s modulus values within the normal
range of 10–40 kPa
In the majority of cases, diffuse thyroid enlargement is a symptom of AITD,
Graves’ disease, or results from thyroid lesions.
The following US signs are characteristic of diffuse hyperplasia of the thyroid
gland (Figs. 4.1, 4.2, 4.3, and 4.4):
• Increase in thyroid volume.
• Homogeneous isoechoic echostructure with a middle- or ine-grained pattern
(Fig. 4.1).
• Regular accurate margins. The contours of the poles may sometimes appear
rounded.
• A very big thyroid may cause dificulties in visualizing the adjacent organs (ves-
sels, esophagus, etc.) due to their dislocation dorsally or laterally.
The lymph nodes in the neck and supraclavicular areas are not enlarged.
Conclusion: Diffuse thyroid hyperplasia. TIRADS 1.
US specialist:

volume of the thyroid gland in adults is

7.7–25 cm3
in men and 4.4–18 cm3
in women [2]. The width of the thyroid lobe in
adults is about 13–18 mm, its depth is 16–18 mm, its length is 45–60 mm, and the
depth of the isthmus is 2–6 mm.
Sonographically, normal thyroid shows isoechoic homogeneous echostructure,
accurate regular margins, and an echogenic capsule (Figs. 2.4 and 2.5). Echodensity
of the thyroid parenchyma is usually compared with the echodensity of the normal
submandibular salivary gland and is isoechoic. It has higher echodensity than the

Struchkova [6] deines the following norms for blood low in all four
arteries: PSV, 10.4–28.1 cm/s; EDV, 3.1–9.6 cm/s; RI, 0.5–0.75; and PI, 0.7–1.2.
he average color pixel density (CPD) in a
normal thyroid is 5–15%. The average number of color cartograms of various ves-
sels is 0.4–2.5 in 1 cm2
, and the number of color pixels within the normal thyroid
lobe ranges from 5 to 10

Normal thyroid parenchyma exhibits uniform medium elasticity with compres-

sion USE. It is evenly colored with ine- and medium-grained texture, quite sym-
metrical in all aspects (Fig. 2.10a, b). Quantitatively assessed, it exhibits the average
Young’s modulus of 12–23 kPa [7–12]. Our own research deined the average value
of the Young’s modulus in the normal thyroid of 11.3 (9.8–22.0) kPa and an average
shear wave velocity of the Virtual Touch Tissue Quantiication technology (ARFI)
of 2.8 (1.7–3.5) m/s (Fig. 2.10c, d).