Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5790_Библиотеки_им_академика_М_И_Перельмана.pdf
134
a
Fig. 3.53 Traumatic spinal canal changes visible on US. ( a ) Sagittal US at lumbar level: extradu-
ral haematoma after lumbar puncture. ( b ) Sagittal section, thoraco-cervical cord level: birth trauma
with cord disruption and haematoma
3 Neurosonography in Neonates, Infants and Children
b
3.7.6 Trauma
Introduction
US only in neonatal period (fi rst orienting bedside study) – decide on urgency &
necessity of additional imaging.
US Findings
• Extramedullary lesions – usually haemorrhages – typically present as echogenic
extrameningeal space-occupying lesion (e.g. after lumbar puncture) (Fig. 3.53a ).
Position/size vary as well as potential mass effect on cord. In chronic stages –
similar to chronic subdural hygroma, become anechoic.
• Nerve root pathology : visualisation diffi cult, depicted by indirect signs/on para-
vertebral views (e.g. haematoma and swelling).
• Oedema, haemorrhage, necrosis or disruption of cord : initially hyperechoic,
disruption of normal cord contour and echotexture with oedematous swell-
ing + mass effect of haematoma, disruption of continuity of external borders in
case of rupture (Fig. 3.53b )
Usually further assessed by MRI (some by CT).
3.7.7 Tumours
Rare, except for congenital tumours listed above (lipoma, dermoid, epidermoid,
haemangioma, cystic teratoma) (Fig. 3.54 ).
Others: Extraspinal tumors that invade spinal canal – neuroblastoma or metastases of cerebral tumours (Fig. 8.26 ). Cause compression of cord with corresponding
symptoms by intraluminal growth.
Spinal vascular malformations – rare, diffi cult to visualise on US and may demonstrate increased vascularity on CDS.
Other spinal pathology (meningitis, focal lesions in demyelinating disease, primary nerve tumours): nonspecifi c changes.
Value of US :
• May depict conditions incidentally and may be useful for bedside follow-up after
surgery.
• Restricted potential, not regularly performed – other sectional imaging preferred
(CT/MRI).
3.7 Ultrasound of the Spinal Canal
Fig. 3.54 Sacral cystic teratoma. Huge congenital sacral teratoma, with large external as well as
internal portion - reaching up to prelumbar levels. Dual/split image technique used to try to demonstrate entire extent, dorsal acquisition (note sacral vertebral bodies with beginning ossifi cation
in upper left image corner)
3.7.8 Other Spinal and Vertebral Pathology
Pathology of Paravertebral Structures
Haematoma, lipoma and abscess formation: see small-part applications.
Disc Pathology
Very rare in childhood.
Discitis may occur – usually manifest in ventral parts and in older child – poorly
accessible by US.
US Findings : Disc looks abnormal and swollen, adjacent tissue oedema (see also
above):
• Normal disc: periphery = − anechoic, homogeneous and ovoid. Centrally more
echogenic nucleus
• If disc herniates into spinal canal sometimes visible by bulging of contour, how-
ever, MRI preferred.
Inflammatory Changes
Meningitis : nonspecifi c US fi ndings, potentially echoes in lumbar CSF space (bac-
terial meningitis).
Osteomyelitis, spondylodiscitis : consider ventral approach – may depict pre-/para-
vertebral pseudotumerous infl ammatory collection at level of disc and diffi cult to
differentiate from tumorous infi ltration.
NOTE : Spondylodiscitis usually manifests in ventral and the intraosseous parts ⇨
poorly accessible by US.
Periosteal/subperiosteal changes : subperiosteal abscess, cortical destruction, etc.
sometimes depicted – however, CT or MRI usually indicated.
135
3.7.9 Additional Imaging
Plain fi lm : for vertebral body malformations – entire spine mandatory. Focal views
in trauma.
Spinal MRI : method of choice for most queries – except for dysraphic changes in
fi rst months of life.
136
3 Neurosonography in Neonates, Infants and Children
CT : used for acute trauma, exact assessment of complex fractures or complex mal-
formations, for planning surgery and for guiding biopsy.
Scintigraphy : spondylodiscitis, osteomyelitis and metastases.
3.7.10 Value of US
• Ideal fi rst step imaging in neonates, in this group often suffi cient
• With increasing ossifi cation less and less effective:
– Replaced/supplemented by other imaging (plain fi lm, CT, MRI).
NOTE : US also valuable for assessing additional or secondary fi ndings in other
body regions (e.g. increasing hydrocephalus after closure of MMC, assessment of
abdominal and cardiac malformations in syndromic disease, evaluation of secondary pathology such as urinary tract disease in children with MMC).
Ultrasound of the Neck
Michael Riccabona
Contents
4.1 Indications, Requisites and Techniques .......................................................................... 138
4.1.1 Transducers ......................................................................................................... 138
4.1.2 Positioning and Handling .................................................................................... 138
4.1.3 Typical Examinations .......................................................................................... 138
4.2 Normal Findings ............................................................................................................. 140
4.2.1 Lymph Nodes ...................................................................................................... 140
4.2.2 Cervical Glands ................................................................................................... 140
4.2.3 Other Cervical Soft Tissues ................................................................................ 143
4.2.4 Cervical Vessels .................................................................................................. 144
4.3 Pathologic Findings ......................................................................................................... 146
4.3.1 Lymph Nodes ...................................................................................................... 146
4.3.2 Pathology of Cervical Soft Tissue ....................................................................... 146
4.3.3 Thyroid Gland ..................................................................................................... 152
4.3.4 Salivary Glands (Parotid, Sublingual, Submandibular Gland) ........................... 155
4.3.5 Cervical Vessels .................................................................................................. 157
4
M. Riccabona
Division of Pediatric Radiology, Department of Radiology,
University Hospital Graz, Auenbruggerplatz 3,
Graz 8036, Austria
e-mail: michael.riccabona@klinikum-graz.at
M. Riccabona, Pediatric Ultrasound,
DOI 10.1007/978-3-642-39156-9_4, © Springer Berlin Heidelberg 2014
137
138
4 Ultrasound of the Neck
4.1 Indications, Requisites and Techniques
4.1.1 Transducers
In general high-resolution high-frequency linear transducers are used:
• Small footprint transducers sometimes very helpful in neonates and infants, pro-
vided that they offer same resolution (e.g. intraoperative/“fi ngertip” probes,
micro-curved) – but fi eld of view restricted.
• For deeper structures (retro-/parapharyngeal space), sector and convex arrays
sometimes necessary.
• CDS: slightly lower frequencies applied, often helpful.
4.1.2 Positioning and Handling
Supine, potentially with pillow behind shoulders for slight extension:
• Sometimes lateral decubitus position necessary – then support head by pillow.
• For cervical vessels – avoid nonphysiologic rotation/bending.
NOTE : Scanning techniques vary with query/targeted structure (e.g. lymph nodes,
glands, vessels).
4.1.3 Typical Examinations
4.1.3.1 Cervical Lymph Nodes
Usually start with submandibular space, work through all stations:
• Always start at unaffected side – less painful.
• Assess all nodes in longitudinal and axial sections.
• For extensive pathology – extended fi eld of view helpful.
• If available and feasible – CDS is helpful to assess vascular anatomy + fl ow
pattern.
4.1.3.2 Glands
Image targeted gland in axial and longitudinal sections, compare to other/nonaffected glands:
• Superfi cial structures may benefi t from stand-off pads (or plenty US gel).
• Always compare left and right side; include surrounding structures:
– Particularly in pathology – assess deeper para-/retropharyngeal spaces when
possible.
• Always use proper labelling and/or pictograms to clearly indicate which site has
been documented; document all relevant fi ndings and standard normal
structures.
NOTE : Perform standardised measurements – use defi nable reference structure to
allow for comparison during follow-up.
4.1 Indications, Requisites and Techniques
ab
Fig. 4.1 Schematic drawing of relevant cervical vessels with respective fl ow patterns on Doppler
US, ( a ) arterial and ( b ) venous
139
4.1.3.3 Cervical Arteries
Initially assessed in cross section (orientation easier) – image up and down as far as
possible. Complementing longitudinal demonstration of course of vessel, include
carotid bifurcation.
CDS: spectral analysis mandatory, particularly of relevant vessel sections and in
stenosis.
Typical vessels: common carotid artery (CCA), internal/external carotid artery (ICA/
ECA) and vertebral artery (VA) exhibit typical and specifi c fl ow patterns (Fig. 4.1 ):
• Rarely target more peripheral vessels (e.g. query vascular malformation, temporal
arteritis).
NOTE : For detailed spectral analysis with velocity measurements proper angle
correction mandatory, with angle <60°!
4.1.3.4 Cervical Veins
Assessed primarily in axial section, imaging upwards and downwards as far as
possible, completed by longitudinal documentation:
• Compression manoeuvres (gentle) allow assessing for stiffness and
thrombosis.
CDS and spectral analysis for confi rmation of initial fi ndings (Fig. 4.1 ).
140
NOTE : For any vascular investigation transducer, pressure may cause artefacts that
mimic pathology; same applies for wrong patient positioning with bending or kinking of vessels.
4 Ultrasound of the Neck
4.1.3.5 Intervention
US used to guide therapeutic procedures:
• Vessel and cyst puncture (IV line placement – e.g. jugular vein, and sclerotherapy
– see Chap.
• Biopsy/puncture/drainage of focal processes such as nodes, tumours or abscesses
(for further details see Chap. 2 “Interventional US”).
2 ).
4.2 Normal Findings
4.2.1 Lymph Nodes
Lymph nodes look similar throughout the body – will not be discussed in other
chapters.
Typical lymph node locations in neck shown in Fig. 4.2a .
US Findings
More or less homogeneous structure of low echogenicity with sharp margins and
ovoid confi guration. Central echogenic hilar structure (Fig. 4.2b ):
• Usually measure <1 cm diameter, length-to-diameter ratio <0.7.
CDS
Exhibit central/hilar vascular supply with regularly brunching vessels (Fig. 4.2c ).
aCDS more sensitive for low fl ow velocities at high insonation angles – better demonstrates peripheral vasculature (Fig. 4.2d ). Helps to depict small peripheral infi ltrations
even in normal-sized lymph nodes – alternatively ce-US improves detection of focal
infi ltration/disrupted vascular architecture in future B-fl ow might further improve
potential.
NOTE : These criteria apply to all lymph nodes everywhere throughout the body;
normal lymph nodes often seen physiologically.
4.2.2 Cervical Glands
4.2.2.1 Thyroid Gland
Composed of two lobes with central isthmus (Fig. 4.3 ).
US Findings
Parenchyma of slightly high, but homogenous echogenicity, potentially with
Echogenicity increases slightly with age.
4.2 Normal Findings
141
a
b
dc
Fig. 4.2 Cervical lymph nodes. ( a ) Scheme (choose one): typical cervical lymph node regions
and distribution. Abbreviations: Level I submandibular space, Level II jugulodigastric space,
Level III venous group, Level IV jugular vein nodes, Level V lateral cervical triangle, Level VI
prelaryngeal, P parotid, N nuchal group and A extra-/para-auricular group. ( b ) Gray scale US
(+ +), ovaloid, >1 cm, hilar structures. ( c ) Normal vascular architecture on aCDS (Power Doppler).
( d ) Spherically enlarged lymph node with focal infi ltration (….) depicted by reduced vascularity
on aCDS
Fig. 4.3 Normal thyroid gland. ( a )
Longitudinal (length, + +) and ( b )
axial section, both images using
dual image technique. SD = thyroid
gland, L = lobe, I = isthmus (→, × ×)
and T = trachea
a
b
142
Table 4.1 Thyroid US
( a ) Normal thyroid size/volume ( in Austria ):
Till 6 years > 4 ml
6–10 years 7.1 ± 3.5 ml
10–13 years 9.7 + ± 6.6 ml
13–15 years 13.0 ± 8.9 ml
15–17 years 14.1 ± 10.2 ml
Grown-up male < 18 ml
Grown-up female < 25 ml
( b ) Volume calculation of thyroid :
4 Ultrasound of the Neck
Schematic drawing: how and where to take measurements for volume assessment, with
respective age-related graph of normal thyroid volume
Note: thyroid size is age, gender and region as well as nutrition dependent
Abbreviations: w width, d depth and l length
( c ) DDx of thyroid lesions
Diagnosis US fi ndings
Simple cyst Anechoic, sharp margin, thin wall, no central echoes
Complicated cyst
(regressive, abscess,
haemorrhage, etc.)
Adenomatous nodule Echoic nodule, echo-poor rim-like border
Adenoma Focal nodule with sharp margins, usually of higher (seldom less)
Regressive nodule Often irregular shape and border and content
Fibrous nodule Very low level echostructure, may be part of adenoma, often
Tumour (carcinoma,
metastasis, lymphoma,
etc.)
Parathyroid gland and
respective adenoma
(a) Normal thyroid size/volume (values from Austria): vol (ml) = l × d × w × 0.48, signifi cant gender
differences only occur with puberty and manifest in adulthood/adolescence
(b) Schematic drawing for standard measurement planes and graph demonstrating age-related (years) normal
values (ml volume) during childhood (in Germany), isthmus diameter neglected for volume calculation
(c) Table to list DDx and kind of typical thyroid lesions
Cyst with often prominent, irregular or thickened wall, central
echoes, potentially septet and levelling
echogenicity than thyroid parenchyma
with calcifi cation
Nonspecifi c echostructure, may grow rapidly, often low
echogenicity, micro-calcifi cation and some inhomogenicity,
unclear and irregular border, may exhibit penetrating-infi ltrating
behaviour, irregular vascular architecture
Usually hypoechoic nodules close to dorsal capsule, or
positioned cranially/caudally to thyroid gland
4.2 Normal Findings
Anterolateral border convex shaped (concave shape indicates increase in size and
may only occur regionally in local infi ltration):
Some mild cystic changes and nodular-patchy parenchymal irregularities may
normally be present in older children.
Size calculated using ellipsoid equation ( L × W × T × 0.48) for each lobe: entire
volume = sum of left + right lobe, volume of isthmus negligible in normal thyroid.
NOTE : Thyroid volume changes with age (see respective growth charts) and shows
geographic regional variation (depending on iodine supply in water and food,
endemic goitre, etc.) (Table 4.1 ). 3DUS more accurate, but new 3DUS-based normal value charts necessary.
Sometimes nodular areas up to 1 cm size of low echogenicity depicted –
particularly close to outer borders in posterior part of gland – represent parathyroid
glands (alternatively positioned next to thyroid gland, then diffi cult to depict particularly in infants).
aCDS
• For demonstration of vascular architecture, vessel identifi cation (DDx cysts) or
displacement (as seen in tumours).
• Necessary for judging (hyper)vascularisation (e.g. in hyperthyroidism or
thyroiditis) and focal vessel disruption/aneurysm (trauma).
143
4.2.2.2 Parotid, Submandibular and Sublingual Glands
US Findings
Parotid gland : slightly patchy, somewhat inhomogenous, echogenic parenchyma
with lobules and hilar vascular supply (Fig. 4.4 ). Parotid duct only visible if
enlarged, particularly in children:
Assessment of duct continuity is diffi cult/impossible.
Submandibular / sublingual gland : echogenicity similar to parotid, but without
lobules, potentially less patchy. Hilar structures less prominent than in parotid.
Ducts usually not identifi ed. Vessels depictable by aCDS.
4.2.3 Other Cervical Soft Tissues
4.2.3.1 Muscles
Resemble normal skeletal muscles throughout body (see Chap. 11 ).
4.2.3.2 Tonsils
Usually seen as hypoechoic lobulated nodular structures in respective location and
may show echogenic bands representing air-fi lled crypts or vessels (see Fig. 4.4 ).
• Physiologically often prominent in childhood.
• Tree-shaped or stripe-like vascular architecture on CDS.
4.2.3.3 Tongue
Nicely seen from submental access and best in axial section.
Has homogeneous structure of muscle-like appearance, potentially with some
slightly higher echogenicity than muscles elsewhere.