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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5770_Библиотеки_им_академика_М_И_Перельмана.pdf
6 Sonography ofOther Neck Masses
97
Fig. 6.3 Lymph nodes (LN)
of the neck. (a) B-scan
sonograph. (b) Color-coded
sonography. The node
includes a hypoechoic area
without blood ow (asterisk),
which is quite suspect for an
abscess. Furthermore, the
surrounding tissue is
thickened as a result of the
strong inammation
a
b
echo is brighter (Fig.6.9). Furthermore, an atheroma is characterized by a hyperechoic acoustic shadow. Blood vessels
can only be detected in the capsule area. In case of an acute
infection, the surrounding tissue shows edematous thickening (Fig.6.10).
6.3.2 Lipoma
A lipoma can be found anywhere in the head and the neck
[3]. In most cases, lipomas have a very thin capsule and a
typically feathered echo inside (Fig.6.11) (Video 6.3). The
98
a
Fig. 6.4 Lymph node (LN)
abscess next to the parotid
gland (PAR). Note the
hypoechoic abscess (asterisk)
with a relative acoustic
enhancement. Furthermore,
the abscess lacks vascularity
Fig. 6.5 Lymph node abscess
in the left neck. (a) Using
B-scan, the two nodes (LN)
impress as inamed lymph
nodes. The surrounding tissue
is hyperechoic owing to
edema. (b) Using color-coded
sonography, it becomes
obvious that one or both
nodesis not vascularized
(asterisk), indicating necrosis
or abscess
P. J e ck er
b
6 Sonography ofOther Neck Masses
Fig. 6.6 Odontogenous
abscess (AB) next to the
mandible (MA). The abscess
area is hypoechoic, without
blood vessels. The
surrounding tissue (asterisk)
is hyperechoic and thickened
because of the strong
inammation
99
Fig. 6.7 Phlegmon and a
small abscess (asterisk) of the
left oor of the mouth. MA
mandible, MHmylohyoid
muscle
feathered echo is similar to the echo of the neck muscles
(Fig.6.12). Therefore it is sometimes difcult to differentiate
normal neck muscles from a lipoma, especially if the lipoma
is small and not palpable, which may occur if it is in a deep
location (Fig. 6.13). Generally, its blood supply is weak,
with only a few blood vessels that can be detected near the
capsule (Fig.6.13).
A diffuse lipomatosis of the neck, such as in Madelung
disease, is characterized by the same pattern as the lipoma:
thickened, fatty tissue showing a feathered structure
100
Fig. 6.8 Atheroma (TU) next
to the right mandible (MA);
the intracutaneous tumor
often has a hypoechoic
structure. Generally the
structure depends on its
consistency. Here, a strong
enhancement of the acoustic
signal is seen between the
arrows
P. J e ck er
Fig. 6.9 Another atheroma
(TU) next to the nasal bone
(NB), with intracutaneous
localization and strong
enhancement of the acoustic
signal behind the tumor
(between arrows). Note that
the tumor itself is more
hyperechoic than the
atheroma in Fig.6.8
6 Sonography ofOther Neck Masses
Fig. 6.10 Acute, infected
atheroma (TU) of the cheek,
with typical echo and typical
intracutaneous location and
enhancement of the echo
(between the arrows). The
surrounding tissue, especially
the masseter muscle (MM),
shows an edematous
thickening due to
inammation
101
Fig. 6.11 A typical lipoma
(TU) with a feathered echo
and a thin capsule. BObone
102
Fig. 6.12 Another lipoma
(TU) of the lateral neck. Note
that the echo often is nearly
the same as the echo of the
muscles (sternocleidomastoid,
SCM)
P. J e ck er
Fig. 6.13 Lipoma (LI) in a
deep location under the
sternocleidomastoid muscle
(SCM). Typically, only a few
blood vessels can be seen
(Fig. 6.14a). In these patients, the lipomatous tissue
frequently can also be detected in deeper regions of the neck
(Fig.6.14b).
In rare cases, the lipoma does not show the typical
feathered structure inside, but instead has a more homog-
enous and hypoechoic structure (Fig.6.15). Especially in
the submandibular region, such a lipoma can mimic a salivary gland tumor. We have found several lipomas with
this pattern even within the head and neck muscles
(Fig.6.16).
a
6 Sonography ofOther Neck Masses
Fig. 6.14 (a, b) Diffuse
lipomatosis (LI) of the neck,
with a typical sonographic
pattern of the subcutaneous
tissue in the whole neck. The
tissue shows a feathered echo,
and no capsule can be
detected. The arrows indicate
the mylohyoid muscle. CCA
common carotid artery, DIG
digastric muscles, SCM
sternocleidomastoid muscle,
THY thyroid
103
b
Fig. 6.15 An atypical lipoma
(LI), in which the typical
feathered structure cannot
be seen
104
Fig. 6.16 Intramuscular
(MU) lipoma (LI) with an
atypical appearance
P. J e ck er
Fig. 6.17 Neurobroma
(TU) of the skin in a patient
suffering from von
Recklinghausen disease.
SMsubmandibular gland
6.3.3 Skin Tumors andInltration oftheSkin
by Metastatic Disease
Skin tumors are very easily detectable by ultrasound. Of
course, ultrasound of the skin is a domain of the dermatologist, who can use high-frequency ultrasound to determine the
thickness of skin tumors and the inltration of the various
skin layers. Nevertheless, the head and neck surgeon will be
confronted with skin tumors that require estimation of the
extent of the tumor, rather than differentiation of malignant
versus benign tumors. Different tumors can occur in different skin layers. Benign tumors (such as the atheroma
described above) are characterized by a clear border, but
other tumors, such as a neurobroma (Fig. 6.17), show a
similar B-scan pattern. Sometimes intratumoral blood ves-
6 Sonography ofOther Neck Masses
Fig. 6.18 Supercial tumor
(TU) of the skin; sonographic
picture and clinical aspect
105
Fig. 6.19 Cutaneous
metastases (CM). The
metastasis is located
supercially and has typical
irregular borders (arrows)
sels can be detected, in contrast to the atheroma, which is
lled with uid. Most skin tumors are hypoechoic. They are
located within the skin level or can be more prominent. With
the ultrasound equipment of the head and neck surgeon, differentiating between kinds of skin tumors—such as between
a basalioma (Fig.6.18), squamous cell carcinomas, or skin
metastasis (Fig.6.19)—is only possible by knowing the clinical picture and the patient’s history. In case of malignancy,
the tumor may show an inltration of deeper structures
(Fig. 6.20). Therefore, preoperative ultrasound of skin
tumors may inuence the radicality of the surgery and should
be part of the diagnostic routine.
106
Fig. 6.20 Clinical aspect and
ultrasound of a squamous cell
carcinoma (TU). Note the
supercial location and the
irregular borders in the depth
of the tumor (arrows)
P. J e ck er
Fig. 6.21 Subcutaneous
process (asterisk) with a
stula (between the arrows)
6.3.4 Fistula
Fistulas can occur anywhere in the skin. Clinically, a stula
is often located in the area of the parotid gland, such as a
postoperative stula, congenital preauricular stula, or lateral cervical stula. Small stulas cannot be seen with ultrasound. Of course, the stula’s duct can be lled with saline
for better detection with sonography and to get an overview
of its extension, but in practice, the clinical impact of this
approach is low. Nevertheless, some stulas can be seen very
well by using ultrasound (Video 6.4). The examiner can frequently detect the connection to the skin (Fig.6.21). Because
of its uid contents, the stula itself is hypoechoic, with an
increased echo behind it.