Ultrasound Imaging

of the Neck
(Chp. 114, Cumming’s
Otolaryngology 7E)

MARK JACOB M. DELA ROSA, MD

1 S T Y E A R R E S I D E N T, O M M C
Key points
High-resolution ultrasound imaging is the “gold standard” modality for nodular thyroid disease and
should include assessment of cervical lymph nodes
Sonographic features suggestive of thyroid malignancy include microcalcifications, irregular borders,
extrathyroidal extension, hypoechogenicity, and increased internal vascularity
Ultrasound-guided fine-needle biopsy is the gold standard technique for thyroid biopsy that reduces
sample error and nondiagnostic rates when compared with palpation-guided biopsy
Sonographic features suggestive of cancerous lymphadenopathy include loss of echogenic hilum,
round shape, microcalcifications, cystic component, irregular borders, and extranodal extension
Basics of Ultrasonography
Ultrasound waves
 propagate through tissue, a small percentage of the
ultrasonic energy (echo) is reflected back to the
transducer.
 US image is formed by the returning wave,
 Strength of the image is proportional to the strength
of the returning wave.

Substances with a greater density produce

stronger “echoes” and appear hyperechoic on
imaging compared with reference structures
Basics of Ultrasonography
Multiple tissue interfaces emit various sonographic echoes and permit generation of readable images

High-frequency waves
 provide better resolution, because smaller wavelengths help detect more minute anatomy, but are also subject to
greater energy loss
 restricted to the evaluation of the superficial structures

Lower-frequency waves
 penetrate more deeply with less attenuation but result in images with less resolution
Basics of Ultrasonography
Multiple tissue interfaces emit various sonographic echoes and permit generation of readable images

High-frequency waves
 provide better resolution, because smaller wavelengths help detect more minute anatomy, but are also subject to
greater energy loss
 restricted to the evaluation of the superficial structures

Lower-frequency waves
 penetrate more deeply with less attenuation but result in images with less resolution
Basics of Ultrasonography
B-mode sonography
 standard gray-scale mode

Doppler sonography
 used for the assessment of blood flow and is
color coded (blue or red), depending on flow
pattern

Echogenicity
 appearance of tissues on the US image relative
to a reference material
Basics of Ultrasonography
Anechoic
 Refers to a complete absence of return
signal
 It represents complete penetration of the energy
through a structure without echoic return
 Appears uniformly black on imaging
 Basics of Ultrasonography
Isoechoic object
 Has similar echogenicity to surrounding tissue and is
typically a midtone
 Normal thyroid and salivary glands are the referent
isoechoic neck structures

Hypoechoic
 tissue has lower echogenicity than reference tissue and
appears darker
 Blackness on imaging

Hyperechoic
 tissue is lighter compared with the reference structure
because of higher echogenicity
 White on imaging
Basics of Ultrasonography
Limitations
 inability to penetrate through bone and cartilage
 difficulty assessing deep visceral and
bony invasion
 cannot reliably evaluate perineural spread,
involvement of the skull base, or the presence of
pathologic lymph nodes in the parapharyngeal,
retropharyngeal, or lower mediastinal region
 operator dependence
Thyroid Ultrasound(US)
•Modality of choice for evaluation of thyroid
disease
•Thyroid gland is one of the easiest structures
to visualize with cervical ultrasound and
should typically appear homogeneous and of
an intermediate gray scale;

•It is considered to be the reference

echogenicity for comparison with other
structures
Thyroid Ultrasound(US)
•US is the most sensitive radiographic modality
for detecting thyroid carcinoma, with a
sensitivity of 80% in experienced hands

•The most accurate modality for measuring

nodular disease
Parathyroid Ultrasound
•Hyper functioning parathyroid adenomas are responsible for 90% to 95% of primary
hyperparathyroidism
•High-resolution US can reliably localize solitary adenomas to correct side and location (right vs. left
and superior vs. inferior) in 80% to 90% of cases

•Localization of enlarged parathyroid glands (100 mg) requires a careful and deliberately slow
transverse (axial) scanning technique.

•Parathyroid adenomas are most often hypoechoic relative to the thyroid gland and are generally
homogeneous.

•Carcinomas may appear irregular and/or calcified

Salivary Gland Ultrasound
•Salivary gland neoplastic disease constitutes less than 3% of head and neck tumors,
although sialadenitis and sialadenosis are relatively common conditions that may
masquerade as neoplasms
•US is ideally suited for evaluation of the submandibular and parotid glands, although
the mandible precludes reliable sonographic evaluation of the parapharyngeal space.
•US can differentiate between neoplastic and inflammatory process, but without US-
guided fine-needle biopsy, it cannot reliably differentiate benign from malignant
neoplasms
•In adult patients, salivary glands have a uniform parenchymal appearance that is
more echogenic than surrounding musculature and similar in echogenicity to the
thyroid
•Multiple hyperechoic linear streaks represent intraglandular ducts.
•Nondilated ducts are usually undetectable with standard probes, but dilated ducts
are easily visualized in chronic sialadenitis with or without sialolithiasis
QUIZ
1. Ultrasound features suggestive of malignancy

2. Ultrasound features suggestive of malignancy

3. Modality of choice for evaluation of thyroid disease

4. Bethesda Grading equivalent of “Benign”

5. 1st Step, diagnostic modality to be requested when entertaining Anterior neck mass, suspected as thyroid mass.

6. Next Step to do when having Bethesda Grade I of FNAB results

7. Normal echogenicity of thyroid gland

8. Percentage of Malignancy of Mass, presenting as Bethesda Grade VI

9. used for the assessment of blood flow and is color coded (blue or red), depending on flow pattern

10. How does ultrasound produces images.