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and edema, associated with regional gland enlargement in the initial phase. Short-interval follow-up ultrasound,whenperformed,canshowprogressionofthehypoechoicpatchestotheadjacentparenchyma, contralateraldiscontinuousinvolvement,ordiffusethyroidinvolvement. Tendernessoverthehypoechoic patchesstronglysuggeststhisdiagnosisintheappropriateclinicalsetting.

10b.  Answer A.  The earlyphase of subacute thyroiditis is characterized by thyroid destruction and

releaseofpreformedthyroidhormone.Aniodine-123scanwouldshowmarkedlydecreasedtraceruptake in the thyroid. The differential diagnosis of low uptake on the thyroid scan in a hyperthyroid patient includes amiodarone toxicity and other causes of subacute thyroiditis such as postpartum thyroiditis. Differential diagnosis for increased radioiodine uptake in hyperthyroid patients includes toxic nodular diseaseandGravesdisease.

References: Frates MC, Marqusee E, Benson CB, et al. Subacute granulomatous (de quervain) thyroiditis grayscale and color Doppler sonographiccharacteristics.JUltrasoundMed2013;32(3):505–511.

RumackCM,WilsonSR,CharboneauWJ.Diagnosticultrasound,4thed.Philadelphia,PA:ElsevierHealthSciences,2011:741–746.

11.  Answer A.  Color Doppler sensitivity in the superficial field of view improves with higher-

frequencytransducersbutatthecostofreducedpenetration.ColorDopplersignalfordeepervesselsand structuresimproveswithlower transducerfrequencies whenthepointofinterestisatthe depthlimitof theimage.So,abalanceisnecessarytooptimizecolorDopplersensitivityandpenetrationfordifferent examinations.Switchingto a lower-frequencytransducer, suchasa 9-MHzlinearprobe, will improve gray-scalepenetrationtobothallowimprovedvisualizationofthedeepparathyroidadenomaanddepict glandhypervascularity.

Increasing the wall filter(choice B) will filter outlow-velocity blood flowcausing reducedcolor Dopplersignalofthedeepadenoma.Spatialcompounding(choiceC),atechniquewhereasinglegrayscaleimageiscreatedby averagingsignalderivedfromsoundsteered atdifferentangles,willimprove the contrast-to-noise ratio and may improve conspicuity of the adenoma but have no impact on color Doppler sensitivity. Increasing color gain (choice D) will improve color Doppler amplification and accentuatevascularity.OptionsB,C,andDwillnotaffectdepthpenetration.

Reference:HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:8–19.

12.  Answer B.  Refraction occurs at the junction of tissues with different sound-propagating speeds

resultinginachangeinthedirectionofthesoundwave.Intissueslikethethyroidgland,refractiveedge shadowingiscausedbytheobliqueangleofthesoundbeamattheedgeoftwotissuesthathavedifferent sound propagation speeds. Thedense fibrous capsule around the periphery ofsome papillarythyroid cancerscancreatethisartifact.Soundattenuationposteriortothe edgeof asolidnodulecausedby this artifactincreasesthelikelihoodthatanoduleismalignant.Insomecases,thefibrotictumorcomposition resultsinshadowingarisingfromwithinthenodule. Theotheroptionsareincorrectdistractors.

References:HenrichsenTL,ReadingCC.Thyroidultrasonography.Part2:nodules.RadiolClinNorthAm2011;49(3):417–424.

Reading CC, Charboneau JW, Hay ID, et al. Sonography of thyroid nodules: a “classic pattern” diagnostic approach. Ultrasound Q 2005;21(3):157–165.

13.AnswerC.Thedistinctlinearnatureoftheechogenicitychangeontheimagebetweenthesuperficial

and deep aspects appears artifactual and should not be confused with pathology. Focal zone banding artifact is caused by mismatched gain that occurs after pasting together of several individual images obtained at eachof the multiple selected focal zones depths. The artifact canbe easily eliminated by reducingthenumberoffocalzones.

Transducer crystal malfunction (choice A) results in dark bands radiating from the surface of the transducer,notinthelateralplane. Thyroidhematoma(choiceB)israreandinfrequentlyreportedinthe radiologyliterature,butwouldnothavealinearappearance.Poortransducertoskincontact(choiceD) usuallyresults when there is aninadequate amount of gel. Dark nonanatomic bandsradiating from the transducersurfaceresult.

References: Fontan FP, Hernandez MS, Vazquez SP, et al. Thyroid gland rupture after blunt neck trauma: sonographic and computed tomographicfindings.JUltrasoundMed2001;20(11):1249–1251.

HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:25–26.

14. AnswerB. Multiple features ofthethyroid nodule are worrisome formalignancy. Thesolid and

uniformconsistencyofthenodulewithhypoechoichaloandlackofmicrocalcificationscanbeseenwith afollicularlesion.Nodulehypoechogenicity andfocalpenetration orinvasionof the nodulecapsuleby smalltumorfocus suggestsfollicular thyroidcancer. Themostimportantimagingfindinginthis caseis the mass in the ipsilateral clavicle, which turned out to represent metastatic follicular carcinoma. Mortality due tofollicular carcinoma is 20% to 30% at20 postoperative years, higher than papillary thyroidcancer.

Follicularcarcinomastendtospreadviathebloodstream.Distantmetastasestobone,lung,brain,and liveraremorelikelythancervicallymphadenopathy.Papillarythyroidcancer,ontheotherhand,usually spreadsvialymphaticsandusuallyaffectsnearbydrainingcervicalnodes.

Reference: Rumack CM, Wilson SR, Charboneau WJ. Diagnostic ultrasound, 4th ed. Philadelphia, PA: Elsevier Health Sciences, 2011:730–732.

15.  AnswerC. People who engagein at-risk behaviors, such as “workarounds” ofconveniencethat

undermine established safety precautions are counseled or coached by removing incentives for the behavior, creating incentives for better choices, and increasing situational awareness. Remedial and punitiveactionsareappliedtopeopleengaginginrecklessbehavior(choiceAandD).Humanerrorsare managedbyconsolementbecausehumanerrorisinevitableandnottheresultofnegligence.

Reference:AmericanBoardofRadiology.DiagnosticRadiology:CoreQualityandSafetyStudyGuide.Tucson,AZ:AmericanBoardof Radiology,2016.

16.AnswerD. Gray-scale andcolorDoppler imagesofthe rightparotidgland show awell-defined,

hypoechoiclesionwithmildinternalvascularityandincreasedthroughtransmission. Themostcommon tumorofthesalivaryglandsispleomorphicadenomaandaccountsfor70%ofallsalivaryglandtumors. Pleomorphic adenomas occurmost oftenin the parotid glandandare benignneoplasms. Theycontain bothepithelialandmyoepithelialtissues,withvariedhistology. Theyareusuallysolitary,unilateral,and slow growing. On ultrasound, they are well-defined, hypoechoic, lobulated tumors with posterior acousticenhancement. Theymayhavemildinternalvascularity.

Warthin tumor (choice A) is the next most common benign salivary neoplasm (5% to 10% of all benignsalivaryneoplasms). They are usuallyoval, hypoechoic, well-defined tumorsand often contain

multiple anechoic/cystic areas. Theyare most likely to be bilateral or multifocal. The mostcommon malignantneoplasmsoccurringinsalivaryglandsaremucoepidermoidcarcinoma(choiceC)andadenoid cystic carcinoma (choice B), but they are much less common than pleomorphic adenomas. Malignant tumorstendtobelarger,morelobulated,andirregularthanbenigntumors,butthereissufficientoverlap. Usually,thesecanbeeasilybiopsiedwithultrasoundguidance.

References: Bialek EJ, Jakubowski W, Zajkowski P, et al. US of the major salivary glands: anatomy and spatial relationships, pathologic conditions,andpitfalls.RadioGraphics2006;26(3):745–763.

HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:244–245.

17.AnswerA. TISor “thermalindexsofttissue”indicates the potential riskofbiologic effects from

ultrasound-induced temperatureincreaseinsofttissues. TheTIBindicatesthepotentialriskofbiologic effectsfromultrasound-inducedtemperatureincreasesinbone. Themechanicalindex(MI)indicatesthe potential riskofbiologic effectsfrom ultrasoundbecause ofmechanicalmechanisms such as cavitation andradiationpressure. THIstandsfor“tissueharmonicimaging.”

Reference:BigelowTA,ChurchCC,SandstromK,etal.Thethermalindex.JUltrasoundMed2011;30(5):714–734.

18. AnswerA. Gray-scale and color Doppler images of the rightneckshow a roundcystic/necrotic

mass with internal septations and solid components. In an adult patient, a cystic neck mass is most concerningforacystic/necroticlymphnode. Thesecanbeseeninthesettingofsquamouscellcancerof theheadandneckandinpapillarythyroidcancer.Ifthereispresenceofpunctatecalcificationswithinthe solidcomponentofthe cysticnode,carefulsearchforprimarypapillarycarcinomainthethyroid gland shouldbeperformed.Acommonpitfallistoattributealargecysticnecklesioninanadultasabranchial cleftcyst.However,becausethemajorityofcysticnecklesionsinadultpatientsaremalignant,thelesion shouldbeconsideredmalignantuntilprovenotherwise.

Mycobacteriumtuberculouslymphadenitis(choiceB)hasapredilectionfortheposteriortriangleof theneck.Onimaging,anecroticdiscreteorconglomeratelymphnodalmasswithsurroundingsofttissue edema is seen.Colloid (choice C) is commonly seen in fine needle aspirate from colloid nodules or colloid cysts ofthe thyroid gland. This lesion isclearly externaltothe thyroid gland. Itis in the right lateral neck lateral to the common carotid artery and internal jugular vein. Hemosiderin-laden macrophages(choiceD)canbe seenalongthe wallofoldhematomas.However, neckmassesresulting fromtraumawillhaveacharacteristichistoryandphysicalfindings.

References:EisenmengerLB,WigginsRH.Imagingofheadandnecklymphnodes.RadiolClinNorthAm2015;53(1):115–132.

HertzbergBS,MiddletonWD.Ultrasound:therequisites,3rded.Philadelphia,PA:Elsevier,2016:242–244.

5 Scrotum

Questions

1.A25-year-oldhealthymalepresentswithpainlesslefttesticularmass.Whichofthefollowingwhen

presentisthemosthelpfuldistinguishingfeatureofthelesionshownintheimageshere?

A.Wellencapsulatedwithsharplydelineatedborders B.LackofvascularflowoncolorDoppler C.Normalbackgroundtesticularparenchyma D.Alternatinghypo-andhyperechogenicconcentricrings

2.Apatientisreferredforascrotalultrasoundforacutescrotalpain.Heisconcernedaboutthepotential

risksofultrasoundincludinginfertility.Whatisthebestcourseofaction?

A.Performtheultrasoundaftertellinghimthatsoundwavescannotpossiblycauseharm. B.Tellhimthatyouunderstandhisconcerns,andreturnhimtotheemergencydepartment. C.AgreenottouseDopplerultrasoundtoimagehistestes. D.Tellhimthatthebenefitsofthisstudyfaroutweightherisks,ifany,thatexist.

3.Howmanygraylevelsareusuallydisplayedinultrasoundimages?

A.24(i.e.,16) B.26(i.e.,64) C.28(i.e.,256) D.210(i.e.,1,024)

4a.  A 70-year-old manpresents to the emergency department with diffuse scrotal pain and swelling.

There is no history of trauma.Of the following choices, which underlying illness does he most likely

have?

A.Lymphoma B.Congestiveheartfailure C.Pseudomembranouscolitis D.Diabetesmellitus

4b.Whichofthefollowingistheappropriatemanagementforthispatient?

A.Consultationwithmedicaloncologist B.Echocardiogram C.Opticalcolonoscopy D.Emergentsurgicaldebridement

5.A28-year-oldmanpresentstotheemergencydepartment,andatesticularultrasoundisrequested.The

historyprovidedbytheEDis“rightscrotalswelling.”Ofthefollowingchoices,whichisthemostlikely correcthistory?

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