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6 Sonography ofOther Neck Masses
Fig. 6.38 This thyroglossal
cyst (CY) with the shape of a
buttery is located
paramedian under the
infrahyoidal muscles (IHM).
HY hyoid, SM suprahyoidal
muscles, TO tongue
117
Fig. 6.39 A septated
thyroglossal cyst (CY). HY
hyoid, SM suprahyoidal
muscles, TO tongue
for both B-scan and color-coded sonographic characteristics
(Fig.6.44). Similarly, sometimes thyroid tissue also can be
detected in the tongue base area (Fig.6.45).
If thyroid tissue is seen within a thyroglossal cyst, we must
consider the possibility of malignant transformation, just as in
the thyroid gland itself. Therefore, we must differentiate these
nodules, similar to thyroid nodules, as explained in other chapters. For example, a spongiform nodule next to the hyoid probably indicates a benign process in the thyroglossal cyst
(Fig. 6.46). But heterogeneity of the tissue within the thyroglossal cyst and additional microcalcication (Fig. 6.47) is
highly suspect for thyroid cancer and needs further evaluation.
118
Fig. 6.40 A small, stulating
thyroglossal cyst (between the
arrows) next to the hyoid
(HY). SM suprahyoidal
muscles, TO tongue
P. J e ck er
Fig. 6.41 Infected
thyroglossal cyst (CY). The
tissue is edematous and
thickened. HY hyoid,
SM suprahyoidal muscles,
TO tongue
6 Sonography ofOther Neck Masses
119
Fig. 6.42 Sagittal view (a)
and transverse view (b) of an
infected thyroglossal cyst
(CY), which is only located
proximal to the hyoid (HY)
within the tongue base.
SM suprahyoidal muscles,
TO tongue
a
b
120
P. J e ck er
a
b
Fig. 6.43 Sagittal view (a) and transverse view (b) of an infected, irregularly shaped thyroglossal cyst (CY), located within the tongue base. After
antibiotic therapy (c), the cyst was much smaller and was resected successfully. HY hyoid, SM suprahyoidal muscles, TO tongue
6 Sonography ofOther Neck Masses
121
Fig. 6.43 (continued)
c
Fig. 6.44 Typically located
thyroglossal cyst (CY)
containing thyroid tissue. The
echo within the cyst is
homogenous and comparable
to that of the healthy thyroid
gland. In contrast to cysts
lled with uid, the detection
of blood vessels indicates the
presence of solid tissue. HY
hyoid, SM suprahyoidal
muscles, TO tongue
122
Fig. 6.45 Thyroglossal cyst
(CY) distal and proximal to
the hyoid (HY), containing
thyroid tissue. SM
suprahyoidal muscles,
TO tongue
P. J e ck er
Fig. 6.46 Thyroglossal cyst
(CY) in typical location with
spongiform tissue inside,
characteristic of benign
thyroid tissue. Note the
contact with the hyoid
(arrow). SM suprahyoidal
muscles
6 Sonography ofOther Neck Masses
Fig. 6.47 Thyroid tissue in a
thyroglossal cyst (CY). The
tissue is heterogenous, with a
necrotic area (asterisk) and
microcalcications (arrow).
Histological examination
revealed papillary thyroid
cancer. HY hyoid, SM
suprahyoidal muscles,
TO tongue
123
6.5 Solid Tumors oftheNeck
Solid tumors of the neck are due to various entities. Most of
them are enlarged lymph nodes, and a detailed description of
sonographic characteristics of lymph nodes can be found
elsewhere in this book. Other, relatively rare tumors of the
neck also can be identied correctly by ultrasound.
6.5.1 Carotid Body Tumor
Carotid body tumors can be detected by B-scan plus colorcoded sonography with a sensitivity of nearly 90% [8]. The
location of the tumor is typically in the area of the bifurcation, which results in a splaying of the internal and external
carotid artery (Video 6.7). The tumor appears homogenous
and hyperechoic (Fig.6.48a) and can be easily misdiagnosed
as an enlarged lymph node on the basis of its B-scan appearance. With the normal setting of the ultrasound unit, intravascular vessels cannot be seen in the carotid body tumor
because of the slow blood ow in small tumor vessels.
Therefore, the pulse repetition frequency has to be adjusted
for low ow [2]. Then the characteristic hypervascularization of the tumor, which allows us to distinguish carotid body
tumor from other tumors in this area, can be seen [9]
(Fig 6.48b). Thus, ultrasound should be the rst imaging
method to detect or to exclude recurrent disease (Fig.6.49).
It is also appropriate for screening of family members of
patients with a carotid body tumor, as a familial predisposition is described in 10–50% [9].
Color-coded ultrasound is especially useful in differentiating between a carotid body tumor and anatomic variations
in this region (Fig.6.50). Inamed lymph nodes also may
resemble small carotid body tumors, but these nodes commonly are lateral to the bifurcation, not between both carotid
arteries (Fig.6.51).
6.5.2 Neurinoma
Neurinoma or schwannoma of the neck can originate from
several nerves. Similarly to carotid body tumors, neurinoma
of the vagal nerve can splay the bifurcation (Fig.6.52) [2].
Sometimes a connection to the nerve can be identied. The
tumor itself has a characteristic heterogenous pattern and a
thicker capsule than carotid body tumors (Video 6.8). But the
most impressive difference from carotid body tumors is the
rarity of blood vessels in the neurinoma (Fig.6.53).
6.5.3 Rare Tumors
In clinical routine, the head and neck surgeon is confronted
with many other tumor entities, but because they are rare, the
surgeon may have little experience with ultrasound imaging
of such tumors, and the correct diagnosis often depends on
other imaging modalities. Nevertheless, ultrasound should
always be the rst imaging method used to get a rst impression of such tumors, which is the requirement for a differentiated indication for further imaging.
124
Fig. 6.48 Large carotid body
tumor (RF) of the left neck.
(a) High pulse repetition
frequency (PRF), −18.2cm/s
(arrow). (b) Low PRF,
−1.86cm/s (arrow). CA
carotid arteries, SM
submandibular gland
P. J e ck er
a
b
Metastatic lymph nodes (Fig.6.54) must be suspected in
patients suffering from any malignant disease.
Ectopic thyroid tissue [2] can occur anywhere in the neck
and can easily be diagnosed with ultrasound (Fig. 6.55a),
even if it is very small (Fig.6.55b). Other imaging techniques are unnecessary in these patients. Especially if criteria of malignancy can be seen, CT scans with iodized contrast
agents are obsolete. Furthermore, ectopic thyroid tissue,
which should always be removed, should not be confused
with a physiological pyramidal process (Fig.6.55c).
Other tumors can occur in the laryngeal skeleton
(Fig. 6.56) or even next to the spinal column or the skull
base. Tumors in the skull base area can be difcult to detect
by ultrasound because they are deeply located. If there is suspicion of tumor in the skull base area, we prefer the use of a
5 MHz sector array, which normally is used in abdominal
ab
6 Sonography ofOther Neck Masses
125
Fig. 6.49 Small carotid body
tumor (TU) of the left neck,
typically located between
both carotid arteries (CA). (a)
Color-coded sonography (left)
and B-scan (right) showing
the preoperative situation. (b)
Postoperative situation.
SMsubmandibular gland
a
b
Fig. 6.50 Atypical course of the internal jugular vein (asterisk) between the external carotid artery (ACE) and the internal carotid artery (ACI).
(a) B-scan. (b) Duplex scan, power mode
126
Fig. 6.51 Small tumor (TU)
next to the bifurcation, not
between both carotid arteries
(CA). This is probably a
lymph node. SM
submandibular gland
P. J e ck er
Fig. 6.52 (a) Vagal
neurinoma (TU) spreading the
right bifurcation. Even if a
low pulse repetition frequency
is used, only rare vascularity
can be detected. (b) B-scan
characteristics of the
neurinoma. ECA external
carotid artery, ICA internal
carotid artery, SM
submandibular gland
a
b