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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5770_Библиотеки_им_академика_М_И_Перельмана.pdf
198
Fig. 9.24 Lymphatic malformation. An 11-month-old boy. The deeper mediastinal parts can be seen only on MRI
J. Weidemann and G. H. A. Engelcke
Fig. 9.25 Reactive cervical lymphadenopathy. A 5-year-old boy. The
lymph nodes are still oval. The vascular architecture is preserved. (See
Videos 9.10–9.13)
Fig. 9.26 Epstein-Barr virus (EBV) infection. A 10-year-old boy.
Increased vascularization with preserved vessel architecture
ab
cd
9 Pediatric Sonography oftheNeck: Characteristic Findings
Fig. 9.27 Atypical mycobacteriosis. A 3-year-old boy. Purulent intranodal inammation of a lymph node (asterisk) with the beginning of a
chimney-like stula due to atypical mycobacterial infection. (See Video 9.14)
199
Fig. 9.28 Proven lymph node infection with Mycobacterium avium. A
4-year-old girl. Several weeks of neck swelling. The rst ultrasound (a)
shows a swollen lymph node with a chimney-like abscess (asterisk).
After drainage without lymph node removal, a decrease in the size of
the lymph node with increasing calcication occurs over a period of
9months (b) 12months (c) and 33months (d)
200
J. Weidemann and G. H. A. Engelcke
Fig. 9.29 Nodular sclerosis classical Hodgkin lymphoma (NSCHL). A 16-year-old boy. Lymph nodes show a roundish form with loss of hyper-
echoic hilus. (PET/CT image courtesy of Department of Nuclear Medicine, Hannover Medical School, Germany)
Fig. 9.30 Nodular sclerosis classical Hodgkin lymphoma (NSCHL). A 15-year-old boy. Supraclavicular lymph node enlargement (asterisk) is
highly suspicious for malignancy. (PET/CT image courtesy of Department of Nuclear Medicine, Hannover Medical School, Germany)
9 Pediatric Sonography oftheNeck: Characteristic Findings
Fig. 9.31 Langerhans cell
histiocytosis. A 3-year-old
boy. Two weeks of neck
swelling. Inhomogeneous
hyperechoic lymph node (a).
Bony lesions with soft tissue
were found in the skull (b)
and lower jaw (c)
a
201
bc
Fig. 9.32 Fibromatosis colli. A 4-week-old girl. Mild torticollis and palpable neck tumor. Focal enlargement (asterisk) of the left sternocleido-
mastoid muscle. (See Videos 9.15 and 9.16)
202
Fig. 9.33 Ganglioneuroma. A 4-year-old boy. The radiograph shows a mass of the upper mediastinum (asterisk). Ultrasound shows focal calci-
cations in a soft-tissue mass. (Ganglioneuromas may demonstrate calcications)
J. Weidemann and G. H. A. Engelcke
Fig. 9.34 Lipoma of the neck. A 10-year-old girl. Typical pattern of
subcutaneous fatty tissue. (See Video 9.17)
Key Points
• Cystic mass lesions may be caused by branchial cleft
cysts, cystic/necrotic inflammatory or malignant
lymph nodes, or by cystic lymphatic vascular
malformations.
• Ectopic thymic tissue may occasionally be found cranially to the mediastinal thymus.
• Viral and bacterial lymph node enlargements are among
the most common masses in the necks of children.
Decisive for the differential diagnosis and therapy are
form, vascularization, presence of purulent foci, and
stulas.
• Malignant tumors in infants are usually neuroblastomas,
lymphomas, or rhabdomyosarcomas; in older children, these
tumors are mainly lymphomas or thyroid carcinomas.
• Vascular anomalies and masses can be classied as
tumors and vascular malformations according to the
International Society for the Study of Vascular Anomalies
(ISSVA).
• Fibromatosis colli typically occurs as a lateral neck swelling with accompanying torticollis in infants between
weeks 2 and 8, caused by brosis of the caudal third of
the sternocleidomastoid muscle.
9 Pediatric Sonography oftheNeck: Characteristic Findings
203
Fig. 9.35 Lipomatous tumor. A 21-month-old girl. Fatty tissue with some septations and inhomogeneous texture. A T1-weighted MRT without
fat suppression (right) conrms the fatty nature of the lesion. (See Video 9.18)
Fig. 9.36 Neurobroma. A 5-year-old girl. Neurobromatosis 1 (NF 1). Nodular tumors around the right vagal nerve and amorphous tissue in the
right renal hilum. A fat-saturated T2-weighted MRT (right) shows the full extension of both lesions. (See Video 9.19)
204
J. Weidemann and G. H. A. Engelcke
Fig. 9.37 Infantile myobroma. A 1-month-old girl. Oval soft-tissue
tumor without a vascular hilum as in a lymph node. The sonographic
picture is nonspecic; other soft-tissue tumors (sarcomas) would be
References
1. Koch B, Hamilton BE, Hudgins P, Harnsberger HR. Diagnostic
imaging: head and neck. 3rd ed. Philadelphia: Elsevier; 2016.
2. Rumack C, Wilson S, Charboneau JW, Levine D.Diagnostic ultrasound: pediatrics. 4th ed. Philadelphia: Elsevier; 2014.
3. Koch BL. Cystic malformations of the neck in children. Pediatr
Radiol. 2005;35:463–77.
4. Richman DM, Benson CB, Doubilet PM, Peters HE, Huang SA,
Asch E, et al. Thyroid nodules in pediatric patients: sonographic
characteristics and likelihood of cancer. Radiology. 2018;288:591–9.
5. Mussa A, De Andrea M, Motta M, Mormile A, Palestini N, Corrias
A. Predictors of malignancy in children with thyroid nodules. J
Pediatr. 2015;167:886–92.
possible. A T2-weighted MRT without fat suppression (right) also
shows an unspecic soft-tissue signal
6. Avula S, Daneman A, Navarro OM, Moineddin R, Urbach S,
Daneman D.Incidental thyroid abnormalities identied on neck US
for non-thyroid disorders. Pediatr Radiol. 2010;40:1774–80.
7. ISSVA Classication of Vascular Anomalies ©2018 International
Society for the Study of Vascular Anomalies. Available at http://
www.issva.org/classication. Accessed 16 Sept 2018.
8. Restrepo R, Oneto J, Lopez K, Kukreja K.Head and neck lymph
nodes in children: the spectrum from normal to abnormal. Pediatr
Radiol. 2009;39:836–46.
9. Golriz F, Bisset GS 3rd, D’Amico B, Cruz AT, Alade KH, Zhang W,
Donnelly LF. A clinical decision rule for the use of ultrasound in
children presenting with acute inammatory neck masses. Pediatr
Radiol. 2017;47:422–8.
Sonography oftheLarge Neck Vessels
andofTumors withSuspected
Infiltration oftheLarge Neck Vessels
HansJ.Welkoborsky
10
Exact knowledge of vascular anatomy and vascular ultrasonography is crucial for head and neck surgeons. Blood vessels in the neck can be altered either by diseases of the
vessels (e.g., atherosclerosis, thrombosis, malformations) or
by tumors in the neck. Furthermore, some diseases show
characteristic vascular sonographic pattern. This chapter
demonstrates vascular anatomy, sonographic, and Doppler/
duplex sonographic characteristics of particular vessels.
Sonographic criteria of atherosclerosis and carotid artery stenosis are also detailed, as well as inltration of large vessels
in the neck by a given tumor.
10.1 Introduction
For ENT surgeons, knowledge of vascular ultrasonography
in the entire neck, with both its normal and pathological ndings, is of great importance. Besides diseases of the neck
vessels themselves, neck masses, lymph node diseases, and
other diseases can alter the neck vessel anatomy. Furthermore,
some neck diseases develop an inltrative growth pattern
involving the large vessels, especially the carotid artery and
the internal jugular vein. Another indication for vessel
sonography in the neck is the assessment of tumor vascularization and perfusion. With modern ultrasound equipment
and high-resolution multiband transducers, it is possible to
visualize blood vessels down to a diameter of about 1mm.
This chapter focuses on the description of ultrasound characteristics of diseases of the large neck vessels themselves and
on estimation of vessel inltration by a given tumor.
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978-3-030-12641-4_10) contains supplementary material, which is available to authorized users.
H. J. Welkoborsky (*)
Department of Otorhinolaryngology, Head and Neck Surgery,
KRH Nordstadt Clinic–Academic Hospital, Hannover, Germany
e-mail: hans-juergen.welkoborsky@krh.eu
10.2 Anatomical Remarks
The large blood vessels in the neck are the common carotid
artery, the carotid artery bifurcation, the external and internal
carotid arteries, the vertebral arteries, the internal jugular
vein, and the facial vein. Most of these vessels are easy
accessible for ultrasound imaging, as they are fairly supercial in the neck and create signicant acoustic impedance
differences.
The carotid artery is one of the large vessels supplying the
brain with blood. The right common carotid artery arises
from the branches of the brachiocephalic trunk. It arises in
the neck in one compartment together with the internal jugular vein, beneath the sternocleidomastoid muscle. In the
vicinity of the second to fourth cervical vertebra (in most
cases at the level of the third cervical vertebra), it bifurcates
into the external and internal carotid artery. The left common
carotid artery arises directly from the aortic arch and enters
the neck in the vicinity of the seventh cervical vertebra. It
arises in the neck also together with the internal jugular vein
and bifurcates into the external and internal carotid artery
(Fig.10.1). The external carotid artery courses on both sides
medial-cranially and is responsible (with its branches) for
the blood supply of the neck soft tissues, the face, salivary
glands, oral cavity, larynx, parts of the thyroid gland, and
tongue. The largest branches of the external carotid artery
(from caudal to cranial) are the ascending pharyngeal artery,
superior thyroid artery (with the superior laryngeal artery),
lingual artery, external maxillary artery, occipital artery, sternocleidomastoid branches, facial artery, and posterior auricular artery. The external carotid artery terminates with the
internal maxillary and with the supercial temporal arteries
as their terminal branches. Many branches of the external
carotid artery are assessable by ultrasonography, at least at
their origin when they arise from the main vessel. In cases of
internal carotid artery occlusion, the branches of the external
carotid artery become important collateral pathways, especially the branches that communicate with the ophthalmic
© Springer Nature Switzerland AG 2019
H. J. Welkoborsky, P. Jecker (eds.), Ultrasonography of the Head and Neck, https://doi.org/10.1007/978-3-030-12641-4_10
205
206
ab
H. J. Welkoborsky
ACE
ACI
Fig. 10.1 Carotid artery bifurcation. (a) The common carotid artery
(CCA) bifurcates into the external carotid artery (ACE), which is
located usually anteriorly in the transverse section, and the internal
artery (i.e., the facial artery, angular artery, trochlear artery,
meningeal artery).
The internal carotid artery does not have any branches in
the neck. The vessel courses after the bifurcation more
dorsal- cranially and passes the skull base through the carotid
artery canal. The vessel then crosses the petrous bone and the
lateral aspect of the sphenoid bone up to the cavernous portion in the vicinity of the cavernous sinus with the carotid
artery siphon. In this area, the ophthalmic artery with the
superior and posterior ethmoid arteries arises from the vessel. The internal carotid artery then forms a part of the circle
of Willis, joins the posterior communicating artery, and terminates into the anterior and middle cerebral arteries.
Sonographically, the internal carotid artery can be assessed
from the bifurcation up to the inframandibular space.
The internal jugular vein can be assessed by ultrasound
along its entire length from the supraclavicular fossa to the
area of the posterior belly of the digastric muscle. In many
cases, the facial vein and its junction with the internal jugular
vein are visible, which is important from a clinical point of
view, as many lymph nodes are located in this area, which is
a preferred site for lymph node metastases arising from
malignant tumors of the oor of the mouth, oral cavity, tonsils, tongue, oropharynx, and salivary glands (Fig.10.2).
The vertebral arteries are other large vessels in the neck
that are accessible for ultrasound examination. The right and
left vertebral arteries arise directly from the subclavian arteries. They ascend and enter the costotransverse foramen at the
level of the seventh or (more frequently) the sixth cervical
vertebra. They course through the transverse foramina of the
transverse processes of the cervical vertebra up to the second
cervical vertebra; then, behind the atlas, pass the dura; and
enter the intracranial space via the foramen magnum. Along
the way, they give several branches to the deep neck and
carotid artery (ICA), which is located more dorsally. (b) In the axial
section, the external carotid artery appears more supercial than the
internal carotid artery
Fig. 10.2 Internal jugular vein in longitudinal section. It is more chal-
lenging to visualize the internal jugular vein than arteries because this
vessel can easily be compressed, even with slight pressure of the ultrasound transducer. Performing a Valsalva maneuver often helps to better
display the vein. (See Video 10.1.) Note the Doppler signal of the vein,
which indicates a permanently low ow; no pulsation is visible. In some
cases, the facial vein can also be seen, forming an angle with the internal jugular vein in which some lymph nodes are located
nuchal muscles, which form an anastomosis to the occipital
artery from the external carotid artery (occipital-vertebral
anastomosis). During the intracranial course of the vessels,
branches include the posterior and anterior spinal arteries
and the posterior inferior cerebellar artery, supplying blood
to the medulla, cerebellum, and parts of the inner ear. Both
vertebral arteries then unite to form the basilar artery, which
maintains part of the blood supply of the posterior cerebral
fossa, parts of the cerebellum, parts of the temporal lobes,
and the occipital lobes. Ultrasound examination of the vertebral arteries is more challenging than that of the carotid
10 Sonography oftheLarge Neck Vessels andofTumors withSuspected Inltration oftheLarge Neck Vessels
tion to the large vessels are preferably performed with the
patient sitting or lying. Small multifrequency ultrasound
transducers with an appropriate frequency band of 7–12MHz
are suitable for B-mode sonography.
Examination of the carotid arteries and jugular vein
includes transverse (axial) and longitudinal scans of the vessels. The patient is placed in a supine position with rotation
of the head of about 45° to the contralateral side. First, conventional B-mode sonography is performed for identication
and orientation of the large vessels (Fig.10.4). This technique makes it possible to evaluate the morphology of the
vessel, such as intima-media thickness, atherosclerotic
plaques, or aneurysms. With additional C-mode, a twodimensional color-coded ow image is superimposed over
Fig. 10.3 The visualization of the vertebral artery is more challenging
than that of the carotids because the vessel courses through the foramen transversarium in the transverse processes of the cervical spine
and can be visualized only in the intravertebral segments . Courtesy of
Dr. Silke Hörnschemyer-Decker, Dept. of Neurology, Nordstadt
Clinic, Academic Hospital, Hannover, Germany
the B-mode image, allowing the visualization of ow velocities and ow direction (Fig.10.5).
The transducer is now moved more distally, to the carotid
artery bifurcation, to identify the internal and external carotid
artery. The external carotid artery is frequently smaller than
the internal carotid artery and has branches, so that its identication should not be a problem. From each section, a rep-
arteries, as its exposition is limited by its anatomy. In contrast to the examination of the carotid arteries, the vertebral
arteries cannot be visualized continuously along their entire
cervical length, but only in the intervertebral segments and at
the atlas-loop portion (Fig.10.3). In slim patients, the origin
of the vessel from the subclavian arteries also can be
visualized.
resentative B-mode image is taken, along with spectral
analysis (Doppler mode). The spectral cursor is placed inside
the vessel parallel to the vessel’s wall and in the center of the
blood ow. The angle of insonation should be adjusted to the
vessel’s course and should be kept to 60° or lower.
The carotid artery appears in axial planes as a round shape
with a hypoechoic center and a more hyperechoic border, in
which different layers, representing the tissue layers (intima,
adventitia, muscularis), can be identied (Fig. 10.6). The
structure is not compressible; it does not change its shape
10.3 Technical Remarks
when compressed by the ultrasound transducer.
The internal jugular vein is located lateral to the carotid
For examination of the large blood vessels in the neck and
assessment of the perfusion of some neck masses, the ultrasound machine to be used must be equipped with the possibilities of B-mode sonography, C (color)-mode sonography,
and D (Doppler)-mode sonography. Most recently, the
B-ow mode was introduced in many modern ultrasound
machines. This is an angle-independent measurement. Echo
amplitudes of short, successive acoustic pulses are compared
to each other by subtraction. Thus, echoes from moving particles (i.e., blood ow) can be differentiated from other tissues. The difference is visualized in a B-mode picture. The
advantages of this technique are a more precise visualization
of blood ow and no aliasing phenomenon.
The combination of B-mode and D-mode sonography is
called “duplex,” and the combination of B-mode, C-mode,
and D-mode sonography is called “triplex.” To estimate
tumor perfusion, it is important that the equipment can detect
even slow-ow blood velocities (2–5cm/s).
Duplex- and triplex-mode ultrasound examinations of the
large vessels in the neck and of neck masses with close rela-
artery. In axial planes, it is seen as a hypoechoic triangularshaped structure. The borders are much thinner than those of
the carotid artery, and no distinct tissue layers can be identied (Fig.10.7). The jugular vein is compressible. For better
visualization of the vessel, the patient is asked to perform a
Valsalva maneuver, which causes the vessel to enlarge; it can
then easily be identied (Video 10.1). The vagal nerve can be
seen between the carotid artery and the jugular vein, laterally
and attached to the artery.
The pulsation of the carotid artery and jugular vein is different: the artery displays a systolic pulse and no diastolic
pulsation, whereas the jugular vein displays a larger systolic
pulse followed by a diastolic pulse of small amplitude (“double pulse”) (Video 10.2). The examination is then continued
in the second plane (transverse scans) by rotating the transducer about 90°. The vessels appear now with a band-like
hypoechoic shape.
The examination of the vertebral artery is more challenging. The transducer should be directed posteriorly, looking
for the vessel in the vertebral canal of the vertebral bodies.
207